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Fertility Clinics Need Zero Tolerance for Error


Recently, a woman was impregnated at a fertility clinic with another woman’s embryo.  The woman has decided to give birth and give the baby to the biological mother.  This preventable and heart breaking mistake should not have happened.

There have also been mistakes in which parents have had their eggs tested for genetic defects only to have the genetically damaged egg implanted rather than the genetically sound egg.  It is a very costly investment both emotionally and financially.

A California couple discovered that the Laurel Fertility Care Clinic destroyed 7 of 13 viable embryos because they were mistakenly inseminated with the wrong sperm.  In this case the couple had a contract that provided no embryos were to be destroyed and the decision by the clinic prevented the couple from the opportunity to make their own decisions.

What is the cause of this problem? At least in part it is likely connected to the burgeoning demand for fertility treatment in the last several years. A report from Mail OnLine sets forth that the number, in Great Britain, of women going through in vitro fertilization has increased from 23,000 in 1995 to 35,000 in 2009. Yet, the number of facilities who handle in vitro fertilization there has not increased with the numbers of women seeking this treatment.

Last Thursday, Carolyn Savage gave birth to a child belonging to another couple. The embryo was mistakenly implanted in Ms. Savage, but actually belonged to Shannon Morrell. Both Ms. Savage and Ms. Morrell were hoping for a child; because of Ms. Savage’s unselfish act, she will be denied her child, but she will provide another family with their child.

The American Fertility Association issued the following press release:

The American Fertility Association Responds to Alleged Embryo Mix-Up Case in Ohio
September 24, 2009 – An Ohio woman, 40 year old Carolyn Savage, claims a fertility clinic implanted the wrong embryo and that the baby she’s due to deliver the first week in October is not hers.  Several media reports state Savage and her husband plan to give the baby boy to his biological parents.  The name of the clinic is not being released in this very rare alleged case.
The AFA is issuing the following statements regarding the matter:
“If the facts in the Ohio case are concordant with media reports, it’s a very unfortunate circumstance for all concerned, a result not to be minimized or trivialized. The story is newsworthy, however, because it is an extremely rare event.
In 2007, there were 132,262 IVF cycles performed in the United States (Fresh, Frozen and Donor Egg, per the CDC) in which more than 300,000 embryos were placed into the intended recipients. Embryology laboratories have extremely rigorous procedures to maximally ensure public safety and the health of our patients and their children born of IVF.
The Ohio case is rarer than 1 in a million and I speculate that human error, not malintent, will prove to be the root cause. I have every confidence that each IVF program in the country will review their procedures and discuss this case to reinforce what we already know, that the work we do each and every day is very special and that the hundreds of thousands of patients we help each year are counting on us to do our best every day.”
-Alan Penzias, MD, Member, AFA Board of Directors
“Unfortunately, due to the acknowledged negligence of the IVF Physician and clinic, this Ohio couple, by choosing to proceed with the pregnancy, is obligated to afford the other couple the legal rights to this little boy.  Any case, such as this that would go before a court of law, would likely grant full legal and physical custody to the other couple without any visitation to the Ohio couple.  They appear to be aware of this – such an unfortunate event for all parties involved.”
-Theresa Erickson, Esq., Member, AFA Board of Directors; Member, AFA Legal Advisory Council
“As a psychotherapist and co-chair of The American Fertility Association, patients receiving treatments live in fear of this happening to them.  The AFA continues to encourage patients to become educated consumers and ask their treatment providers about their procedures for safeguarding their genetic materials. Programs are required to have in place strict guidelines that are overseen by numerous state and federal agencies requiring very specific procedures to be practiced and in place by each reproductive center.
These incidents are rare and patients should feel assured that the majority of centers follow these rigorous guidelines.  When these rare accidents do occur, it can be not only psychologically devastating to the couples involved in this mix-up but emotional damaging to the thousands of patients who are currently receiving or starting fertility treatments. We at the AFA hope that the media will allow these couples, the children involved, and the baby yet to be born to privately get the support that they need to cope with this emotionally difficult experience.”

This type of error can certainly be characterized by the national association as a “rare” error, but I am sure that neither Carolyn Savage nor Shannon Morrell can find much solace in this representation. Carolyn Savage will undoubtedly always wonder about the baby she brought into this world.

Making the decision to go to a fertility clinic in the hope of trying to conceive a child and/or have eggs tested for genetic factors must be a very difficult decision. All clinics and laboratories should have protocols in place to prevent these devastating errors from happening; causing devastating consequences to the parties involved. This is really a zero error tolerance business engaged in by fertility clinics. Providing an explanation such as that offered by the American Fertility Association is simply insufficient and lacks the very personal consideration due to these victims.

Become an educated consumer. Read, ask questions, be a persistent presence in the process of any medical procedure you undergo.

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