Overview
- Clinic staff performed two back-to-back IVF embryo transfers on July 23 and a name mix-up led to the first woman receiving the other couple's embryo.
- A staff member rechecked records about eight minutes after the transfer and the clinic arranged, with the affected couple's consent, removal of the mistakenly implanted embryo by vacuum aspiration the next day.
- The second couple received a correctly sourced embryo on the same day and were told of the error later after clinicians said they had tried to avoid causing stress during the implantation window.
- Milan's Health Authority and Italy's Ministry of Health ordered a temporary suspension of fertilisation, embryo culture and transfer at the San Raffaele centre while they investigate how multiple checks failed despite the same team performing both procedures.
- The case raises questions about lab and transfer protocols at one of Italy's leading IVF centres and could prompt tighter controls across the country's roughly 300 fertility clinics where more than 80,000 couples seek treatment each year.