Is My Embryo Really Mine? The Truth About IVF Mix-Ups

Every IVF patient has wondered it at least once:
   Is my embryo really mine?

Every so often, a story makes headlines about an IVF mix-up. While these cases are heartbreaking, they are extraordinarily rare — occurring approximately 1–2 times per million IVF births.

In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols breaks down:

• How IVF labs prevent embryo mix-ups
• The role of double witnessing and lab verification
• Electronic witnessing systems (RFID, barcodes, and AI)
• Whether new technology truly reduces errors
• How DNA testing can confirm embryo identity
• Why human vigilance still matters more than automation

You’ll also hear how the risk of an IVF mix-up compares to lightning strikes, car accidents, and even plane crashes.

The goal of this episode is simple: reassurance through transparency.

While no medical process is ever zero risk, IVF is one of the most carefully audited and safeguarded systems in modern medicine — and understanding how it works can help replace fear with facts.

If you or someone you love is going through IVF, this is an episode you don’t want to miss.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:00

Today we talk about one of the greatest fears everyone has, infertility mix ups. I'm Dr. Mark Amols, and this is Taco about Fertility Tuesday. Although very rare, every once in a while a story will break about IVF baby going home with the wrong family. So today we're going to talk about how rare that is and how clinics actually prevent it from happening and how science can now prove those embryos are yours. So let's be honest, for an IVF patient, getting the wrong embryo is probably the greatest fear there can be. Not will it work, but is it mine? When you hear about an embryo mixup, it hits you emotionally because this isn't just a lab error, it's someone's child. And here's the good news. These events are extremely rare. We're talking one to two per million cycles. That's not common. That's a medical unicorn. To give you an idea of those types of risk, the chances of getting struck by lightning is 30 times higher. The chances of dying in a car crash in your lifetime is 10,000 times higher. Even the chances of dying in a plane crash in your lifetime is about two to three times higher. This is how extremely rare these mistakes are. Now, don't get me wrong, they shouldn't happen. And what we're going to talk about is why do they not happen? Why is it so safe? One of the reasons this is such a rare phenomenon is because there are multiple safeguards that are occurring to prevent this. And when something like this happens, it isn't like one safeguard fails. It's multiple safeguards that fail at once. Any good lab should always have a, double witness. Some of the things we do even have triple witnesses. This means that two people verify that step, that is the correct patient and the correct embryo, even before the process starts. One of the first things that happens is they go and they make the dishes and they verify the names. Then before even starting the retrieval, they verify the patient. They walk in the room and the patient verifies themselves. And two people verify that that is the patient. Now, during the retrieval, only that patient's eggs are being worked on by that embryologist. And the eggs are put in a dish that was already labeled by that patient, that was already verified by two people that it was the correct patient. Now, during the egg retrieval, the sperm is being processed. At that point, when the sperm is given, labels are made ahead of time. Then the patient will give the sample, hand it over to the andrologist, and then the andrologist will either check some type of ID and then verify with the person that the sample is theirs that goes into the container that already has their label and then is processed. Some labs will even use color coding. So that way, if they have more than one patient, they will have different colors to help them know. This person always stays blue, this person always stays green. One thing that clinics do to help for safety is they stagger patients. So instead of two people giving a sample, only one person is given a sample, let's say, every 30 minutes. This allows the andrologist then to work on, one sample at a time. And different people are at different steps. So when one person is in a centrifuge, the other one might be in a part where they're processing it in a different way. However, just like in the IVF lab, every step is verified. And it's not that it's verified, it's documented. One interesting thing is some methods, such as the zymon chip, allow the sample to never move from where it was processed because it's just one step. You put the sperm on the chip, and then at that point, the sample is removed from the chip so it never actually moves anywhere. This keeps the chain of custody very minimal. Now, after the retrieval, what happens is again, the petri dish with the patient's name on it is then put in the incubator, which also usually has the patient's name on it. Now, in the past, most clinics used to have these large incubators where multiple embryos would be inside the incubator. Today, most clinics are going to bedside incubators, which are very small and usually have individual chambers. Now, at, our clinic, every single patient gets their own chamber. No patients share a chamber. Now, it doesn't make it wrong if they do, but it's just important to understand that as time has progressed and the technology has got better, it does make it a bit safer when you can take an embryo from a station where only that patient's at versus in the past, with the large incubators, you'd have to find the person in a bunch petri dishes and make sure you have the right one. The checks are still the same. Still, two people should verify it, regardless if they have their own incubator. But like a lot of things on metalkinos podcast, are things that help. But just because they don't do it doesn't make it unsafe. The next day, when they check for fertilization again, they'll verify the incubator, take out the petri dish, verify fertilization, and then put it Back. This whole time it's being verified again by two people. Now, some clinics here may just have the embryos grow out to day five and never check the embryos again. Some may take it on day three. And again, the same thing is going to happen. It's going to be verified by at least two people every step of the way. All this is being documented. And it's not just the embryos are being verified. Every order is also being verified. Now, eventually, either that embryo is going to be transferred or it's going to be frozen. Now most programs are going to be freezing at this point. And so what happens again is two people verify. Special stickers are made to put on the devices for freezing, which are also verified having the patient's name, date of birth and the cycle date and the embryo number. Then this frozen straw is then put in a tank with a canister number, usually has a tab color on it, and sometimes even the straw has its own color. All these things are put there to help identify in the future when they go to get this straw, everything down to the media is documented, even to the lot number. Now, eventually you're going to do a transfer. And if it's a frozen embryo transfer, then there's a lot of steps that need to happen. First, you're going to have at least two witnesses verifying the physician order that the order is correct. Then you're going to have two people verifying that the straw was picked is the correct straw. Then you're going to verify that the straw and the dish match each other, which you then are, thawing the embryo into. Then you're going to verify the patient name and the straw once the patient's in the room. And then at our clinic again, as they come into the room, they'll verify again one more time with the patient saying it out loud, which embryo and to which patient is being transferred. Even when the patient comes to the room, we verify the patient with both, a medical assistant or nurse as well as embryologist. And then again, before even bringing the embryo in the room, another check is done, verifying the correct dish and patient. So as you can see, at every step, identity is checked. So for a mix up to occur, several people, several systems and several moments have to all fail at the same time. So what is the reason for failure then? Well, because we're humans and humans sometimes can make mistakes. If you look at something a thousand times, eventually sometimes you might just misread something because you're human. This is the reason for the second check. And yes. If someone doesn't do that second check, you can see how something could go wrong. If someone doesn't recognize that the straw color was wrong because there wasn't a second check, something could go wrong. But as I mentioned, it is extremely rare. There has been about 25 recorded cases of this and about 12 million live births from IVF. So as you can see, it's a very small number, one to two per million. And as I mentioned, things are getting even better because with time there's a lot of stuff that has happened that's improved it. For example, labeling has got easier. Instead of handwritten labels, now people can use special stickers that go on them that are easier to read. There's new things such as electronic witnessing, which we'll go into a few minutes here, and also DNA testing. You can actually now test the embryos to make sure the embryo matches your DNA fingerprint. Now, in the end, still nothing is perfect. Certain companies that do allow for identification of DNA testing are going to be like Igenomics, Cooper Genomics, Luminary Genetics, Genomic Predictions and several other PGT companies. Now keep in mind, parental origin usually does cost extra money, but for some people it may be worth it. I mentioned a minute ago about electronic witnessing. So as I mentioned, human witnessing is the gold standard. Every clinic should have two embryologists verify every step. This should have no exceptions. Electronic witnessing is kind of like having another person verify. Now, there's different types out there. There's barcode systems, there's RI witnessing which uses RFID tags, and then there's AI now with barcodes, just like you would think. Every single dish has a barcode. They click it and it just verifies that that's the correct patient. The same thing with RFID tags. What it does is it has a little tag on it and as it gets close to the center, it verifies, that's the right patient. And then the person verifies, yep, that's the correct patient. Now AI is very early and still in the experimental stages. But basically it's watching and monitoring and looking for pattern recognitions and seeing if anything is going wrong. So if it sees someone, let's say take a, dish and then doesn't put the dish back and use it again, it would say something. But again, this is extremely new. It's not really being used anywhere as a major form to prevent mix ups. Now if your lab's not using electronic witnessing, don't be worried, it's still new. It's not the standard of Care. And I don't think a lab would be bad for not using it. But I do believe it's going to be the future of fertility. And I eventually think when we can figure out what's the best one and which one's going to have the best utility, it will become eventual standard. The problem still lies in humans. If you label the dish wrong, it doesn't matter how many times you put a barcode and you check it, it's always going to check correct, even though you put the wrong sticker on, which would then have the wrong patient. This is why two embryologists verifying every step is always important. Now, here's the truth about witnessing systems. They're very new to medicine and they're becoming more common. But the thing is, we just talked about that the error rate is so low, that's going to take time to even find out if these are really benefiting. Personally, they worry me at times because as humans, when we rely on other systems, we sometimes get a little bit lazy and don't verify our own because we think, oh, the system is going to catch us. And that's something that can never happen. As I mentioned, humans always need to verify and it always needs to be a double verification, if not even a triple verification. In certain situations. At our clinic, anytime we do a PGT M M case, which is for a monogenetic disorder, we always have three people verify the embryo that's being selected. And this is because it's a high stakes situation. Putting it at the wrong embryo not only can cause the pregnancy to maybe not work, but it could potentially give a baby some disease. And so in that situation the risk is higher and we add another verification. So in the end, if a patient doesn't have electronic witnessing, it doesn't make them a bad clinic. A clinic is not unsafe just because it doesn't have that, but what they have to have and would make them unsafe if they don't have strong double witnessing, if they don't have good labeling or they don't audit things, or they don't have really a culture of safety, I anticipate in the next 10 years we're probably going to see it very common to have both double checks as well as electronic witnessing systems. And, I anticipate it's going to be a hybrid. I don't think one's going to win. I think eventually it's going to be something like AI and barcodes or AI and rfid. So the point is, the goal of this podcast was to help reassure you that the chances of something happening are very small, even though you just heard about it in the news recently. Now, there are exceptions to this rule sometimes. For example, in invocell we call ivc, the patient is always its own incubator. So there is actually zero risk of a mix up because what happens in IVC is the patient goes through retrieval only that patient's being worked on. The eggs and sperm are all put together at the exact same time, put back into the patient where she will then culture it in the invocell pod. Then she comes back in five days, the pod is opened, the embryos are taken out and transferred into her. So the embryos actually never leave her custody in that way. So there are some clinics that do have just one embryologist, but because they're only working on one patient at a time, and because the sperm and egg never come in contact with another sperm or egg, because there's never another patient and goes back into the patient before another patient comes in the room, there actually is no chance of a mix up because there's only one patient in the building at a time. If you're not familiar with ivc, that will be a future podcast. I did think it was important to at least bring up because there are some clinics that only have one embryologist in that situation, but they really don't need two because there cannot be a mix up since there is never another patient. The goal of this podcast was purely to help reassure you. If you ask me, is it possible? Yes. I'm never going to tell someone there is zero risk. But what I can tell you is, is that we tried to make it near zero and it technically is near zero. As I mentioned in the beginning, the chances of this actually happening of a mix up embryo is about 1 to 2 per million. And I'm not even talking about cycles. 1 to 2 per million births from IVF. That means dying in surgery is a thousand times riskier than the IVF mix up. That means getting struck by lightning in your lifetime is 50 times more likely. And the most shocking of them is that your lifetime risk of dying in an airplane crash is at least double the risk of an IVF mix up. Just like you, we want that number to be zero, but it's pretty close. And although no one can ever say there's a 0 chance of a mix up, what we can tell you is we do a lot of things to help prevent it and you should feel overall reassured. Hopefully this podcast helped reassure you. I probably didn't cover every little thing but I tried to cover most of the stuff so people can understand just how rigorous the checking is. I can assure you that it is one of the most important things in a laboratory. If we ever have an embryologist or someone who doesn't have the skill set to constantly keep checking these things, we wouldn't keep them. No one would. This is probably the most important thing when it comes to an embryologist is verification. And hopefully I was able to explain that today well enough that you feel more reassured that your embryo is your embryo. And like we talked about, there are several things you can do, such as been testing embryo for paternal genetics if that helps you even more. Just like we're more improved today than we were 10 to 15 years ago, I expect the next 10 to 15 years it will even get better. It will never be zero, but it's going to even get closer and closer to zero. If this podcast was helpful for you today, or maybe you know a friend who's going through IVF and is worried about these things, let them know about this episode. It might help relieve some of their fears. As always, if you like this podcast, give us a five star review on your favorite medium. Tell your friends about us and most of all, keep coming back. I look forward to talking again next week on Talk About Fertility Tuesday.