Panel finds Assuta Rishon Lezion IVF mix-up due to embryologists’ too-heavy workload

The Health Ministry released on Wednesday its report on the circumstances that led to a couple receiving the wrong IVF embryo at the Assuta Medical Center in Rishon Lezion last September.

The report was prepared by an external committee appointed to determine what caused the error and to recommend guidelines to prevent similar occurrences. The committee is led by Prof. Ami Fishman, a leading obstetrician-gynecologist and deputy CEO of Rabin Medical Center and head of its the department of quality and patient safety.

“The committee determined that there are two other couples who are likely to be the genetic parents,” the report stated.

After reviewing medical records and interviewing medical staff and patients, the panel concluded that the mix-up most likely occurred when  the woman who received the embryo and the genetic mother were both in the clinic’s waiting area at the same time. The women went in for embryo transfer in the wrong order, resulting in the error.

Another possibility is that a third woman, who was scheduled to undergo embryo implantation around the same time, is the genetic mother. However, the chances of are lower since this woman had only one embryo transferred, as opposed to the other two who had three.

Six couples who suspect the child may be genetically theirs have pressed for genetic testing, which so far has been put on hold by the court.

The committee cited significant breaches of protocol and attributed the error to the entire staff rather than to a single person.

“The committee believes that the embryologists’ workload is the reason for not following proper procedures and ‘skipping’ over steps within the protocols,” the report stated.

The report attributed the fact that between 2017 and late 2022, the number of IVF procedures at the hospital increased by tens of percentage points to the government’s shifting fertility treatment to private hospitals such as Assuta. This was financially beneficial for the Health Ministry, private hospitals, and the doctors, but put patients at risk due to the increasing pressure.

According to the report, a chain of errors in properly identifying patients and working with embryos points to serious lapses in operations, supervision, and management.

“From the testimonies before the committee, it appears that Assuta’s patient safety and risk management unit was not involved with the IVF department,” the report stated.

As a result, there was no data on mistakes or near-mistakes that may have taken place.

The panel praised the hospital for helping countless infertile couples have babies and start families, but was critical of the placing of financial considerations above quality treatment and patient safety.

“As a result, this medical institution was turned into a factory assembly line, knocked the cart off the rails, and caused great pain and suffering — not only to the patients involved in the immediate circle of this incident but also to the larger community of patients at Assuta and IVF departments around the country,” the report stated.

While the committee’s investigation was underway, the Health Ministry demanded in October 2022 that the medical center’s fertility department reduce its operations by 50 percent — from 10,000 fertilization treatments a year to 5,000.

The couple that received the wrong embryo has said it wants to keep the child, born in late October, and is reportedly planning to sue the hospital for $3 million.