Comptroller: Health Min. did not ensure IVF unit problems were fixed prior to embryo swap incident

Problems raised in Health Ministry reviews of in vitro fertilization (IVF) units were not corrected in the years leading up to the September 2022 embryo swap incident, according to a report by Israel’s State Comptroller Matanyahu Englman released Tuesday.

While the report did not say that these problems led to the incident, in which parents discovered that the child they conceived through IVF was not biologically related to them, it stressed that some of the problems “have an affinity” to what happened.

The incident came to light after tests showed a pregnant woman who underwent IVF at Assuta Medical Center in Rishon Lezion was carrying a baby that was not genetically related to her or her husband – revealing that the wrong embryo had been implanted during her treatments.

Health Ministry reviews in 2018 and 2019 found significant issues in the IVF units, some of which were “significant and related to the quality and safety of care,” the report said.

Issues were found with identification procedures for patients, missing information on patient charts, lab and lab manager certifications, manpower, and more, said the report.

In spite of this, the Health Ministry did not perform follow-up reviews before the September 2022 embryo-swap incident except in two public units where it found significant problems, the comptroller report said.

Patients exposed to risks, report says

The ministry also did not ensure that the other units were working to handle problems found with their function, even though it found that some of these units had serious problems that required immediate correction.

Problems in the identification of patients are those the report said have an “affinity” to those that caused the 2022 incident.

Some of the serious problems found in the 2018-2019 reviews were also found in 2022-2023 reviews, including problems with identifying patients and lack of manpower, the report added.

“From the Health Ministry’s responsibility and role as supervisor, it is obligated to ensure that the problems raised in its reviews which could hurt patients are addressed,” said the comptroller’s office, adding that the responsibility to fix these issues falls on the hospitals where the IVF units operate.

“The failure to address the serious deficiencies exposed patients to risks,” the report said.

THE REPORT also highlighted the concern that abnormal incidents arising from IVF treatment are not properly reported to the Health Ministry.

While, between 2017 and September 2022, only four reports of abnormal incidents were made to the ministry, between October 2022 and May 2024, seventeen reports of such incidents were made.

“The sharp increase in the rate of reporting extraordinary events in IVF in the time-frame after September 2022 – ten times higher than in the period before this – raises a real concern that [these] events happened before but were not reported to the Health Ministry as necessary.”

The report also commented on “the huge increase in the scope of activity in private IVF units,” which exposes patients to significant risks, the report said.

“Such growth in scale may lead to strain and a decline in the quality of care if not accompanied by adequate preparation in terms of personnel, infrastructure, and appropriate monitoring and oversight mechanisms,” it said, adding that the workload was a central factor in the September 2022 incident, according to an investigation of the event.

“In July 2023, the Health Ministry noted that the additional adverse events that occurred in another unit were also linked to the heavy workload in that unit.”

The report also touched on the storage of unused eggs and fetuses – saying that the Health Ministry has not set instructions on how to defrost them.

This has led to an accumulation of these, including eggs and fetuses from the 1980s. As the accumulations build, some of the units have had to add freezer space, the report added.

“The audit revealed that the accumulation of egg and embryo reserves has significant implications for maintaining storage tanks, managing the risks associated with storing a large number of eggs and embryos, and the costs involved in their preservation,” the report said.

“The Health Ministry is obligated to address the deficiencies to ensure that critical errors are not repeated,” said Englman.

Jerusalem Post Staff contributed to this report.