Causes & Treatment
How common are IVF mix-ups in the UK, versus the rest of the world?
Jessie Day, Senior Editor | 4 Mar 2025
In short, extremely rare. Learnings from decades-old incidents have required the UK to put in place stringent check processes and frameworks, to ensure in vitro mix up likelihood – from mistakes in implanting embryos to other, catastrophic errors – is all-but zero. All-but – so not impossible, but extremely unlikely.
Your clinic should be able to run you through these rigorous checking requirements, any time you ask. But recent headlines covering a heartbreaking embryo implantation error in California, USA, plus IVF with the wrong sperm used – read the story here – have triggered understandable renewed concerns.
So, how common are IVF mix-ups UK-wise, in 2025? Let’s dig in.
The Toft Report, 2004
But first, let’s rewind, to 2002.
In July of that year, Sir Liam Donaldson, Chief Medical Officer for England at the time, commissioned Professor Brian Toft to investigate circumstances surrounding the sperm mix-up – alongside three other incidents – occurring at assisted reproduction units in the Leeds Teaching Hospitals NHS Trust, West Yorkshire.
In this case, two couples arrived on the same day, for treatment at the same facility. Human error, however, heartbreakingly led to a sperm mix-up, with the samples being switched. It was only on the birth of twins to Mr and Mrs A that the error became clear. The twins were mixed race, and the couple were both white.
Key findings and takeaways from Toft’s Report, published in 2004, included serious concerns regarding:
- human error
- poor management
- systems failures
His report made over 100 recommendations for change, heavily criticised fertility services in the UK, the government itself, and the governing body – the Human Fertilisation and Embryology Authority (HFEA).
HFEA, government and services – crucial learnings
Today, the HFEA is an iron rod across UK fertility services, NHS or otherwise. But in 2004, as the Toft Report published, it was accused of operating within a culture of secrecy, alongside other more specific accusations around management and inspection procedure.
The government was also called out on its inadequate funding of the HFEA, alongside clinics and fertility services themselves, for understaffing and lacking facilities.
Crucially, Professor Toft made it clear in his report that since the incidents at Leeds NHS Trust, improvements had already been made. And in a statement, the HFEA welcomed the recommendations, having already put in place 85 per cent of Toft’s recommendations, before the report was published.
The sector – and industry – had learned, at huge personal cost to an unknown number of families. But, what sort of picture are we looking at today?
A witnessing framework, for every clinic
One of the HFEA’s landmark changes, following the Toft Report, was implementing a stringent witnessing framework. Going forward, as part of the HFEA Code of Practice, every clinic – NHS or private – would be required to use the framework, designed to ensure granular, meticulous checking across every stage of the IVF process.
You can read the very latest HFEA Code of Practice here, along with any previous versions.
And while witnessing, and assuring patient and donor identification, makes up one crucial part of the Code of Practice, UK patients also benefit from strict governance around all of the following thanks to its reach, including:
- regulatory principles
- staffing and personnel
- counselling and patient support
- consent
- legal parenthood
- multiple births
- child welfare
- embryo and PGT-A testing, and sex selection
- donor conception, mitochondrial donation, egg sharing and surrogacy
- gamete and embryo transport and storage
- traceability
- research and training
- quality management systems
- third parties
- premises, practices and facilities
- equipment and materials
- adverse incidents
- complaints
- treating people fairly
- confidentiality and privacy
- record keeping and document control
- reporting requirements
In an interview this week published in The Telegraph, Director of Compliance & Information at the HFEA, Rachel Cutting, says “The UK is really the only place that has absolutely formal, highly regulated IVF”.
This is in the context of recent headlines around mix-ups in the US, adding that, the events preceding the Toff Report in the UK in 2002 triggered many crucial learnings and changes,
“That was then the witnessing guidance was really strengthened […] In the code practice, every time you collect eggs, you collect sperm, you prepare sperm, you change tubes, you move embryos, you transfer something – everything is always double witnessed.”
Talking numbers – how common are IVF mistakes?
In its State of the fertility sector 2022/23 report, published in September 2023, the HFEA noted the following key findings, taken from 85 inspections across 2022-23:
- critical non-compliances have decreased to 2%
- no Grade A incidents since 2020/21
- severe/critical OHSS incidents consistent with previous years
- patient complaints decreased
What’s a ‘Grade A’ incident?
A Grade A, at the HFEA, is the most serious type of reported incident amongst the licenced clinics it regulates. In its report (see above), the HFEA notes that:
- around 100,000 treatment and storage cycles are carried out each year, as well as 1,200 new egg donor registrations
- over 99% of these are carried out with no incident reported
- of those incidents, very few are Grade A
Reporting incidents is a statutory requirement. Getting more granular, the HFEA notes that in 2022/23:
- 517 incidents and 89 ‘near misses’ were reported to the HFEA
- just over half of all of these were Grade C, with the remainder being Grade B
- there were no Grade A incidents from 2020/21 to 2022/23
In summary, IVF mix-ups in the UK are extremely rare, largely due to learnings from past incidents occurring over the last two decades, and stringent processes put in place as a result – plus, an overhaul of the HFEA’S funding and set-up.
IVF mix-up stories: A rare but heartbreaking reality
While IVF mix-ups are extremely rare, the consequences of such errors are life-altering for the families involved.
One of the most widely known cases is that of Daphna and Alexander Cardinale in California, USA. Daphna was implanted with the wrong embryos during IVF treatment in 2019. After giving birth to a baby girl who did not resemble either of them, genetic testing confirmed that the child was not biologically theirs.
The error led to a devastating emotional ordeal as the couple later discovered their biological daughter was being raised by another family. After months of navigating the legal system and forming a relationship with the other family, the two couples ultimately decided to switch daughters, reuniting each child with their biological parents.
In another high profile case, a couple from Queens, New York discovered an IVF mix-up only after their twin boys were born. Despite carrying the pregnancy and giving birth, the babies were not biologically related to the parents due to a mix-up at the fertility clinic. The couple had to go through a heartbreaking legal process, ultimately returning the babies to their biological parents.
These incidents highlight the emotional and ethical complexity of IVF mix-ups. They also underscore the need for robust systems to prevent such errors, as well as emotional and legal support for families when the unthinkable happens.
Wrong embryo mix-up in Georgia, USA
Krystena Murray is currently suing Coastal Fertility Specialists after an IVF wrong embryo mix-up led her to unknowingly carry and give birth to another couple’s child.
Expecting to raise a baby conceived with a sperm donor in 2023, Murray realized at birth that the child was not biologically related to her. A DNA test confirmed the mistake, and five months later, she was forced to surrender the baby to his biological parents.
The lawsuit alleges negligence and calls for greater oversight of the IVF industry to prevent such errors, which Murray’s attorney calls a “cardinal sin” for fertility clinics.
What happened in Australia?
In 2024, Australia was in the global spotlight for an IVF mix-up with Queensland Fertility Group at the centre.
In this case, a couple accused their clinic of using the ‘wrong sperm’ after discovering their children are not biologically related. The couple underwent IVF treatment and had three boys, believing the same donor sperm was used for all their children.
However, they later found out that their children are not all biologically related, raising serious concerns about procedure and practice, in clinic and at a national level across Australia.
These revelations emerged during a major investigation by ABC’s Four Corners into Australia’s highly profitable IVF industry.
In the UK, past cases involving IVF treatments using the wrong sperm have raised significant concerns about the oversight and protocols within fertility clinics. Alongside being completely devastating for the families involved, these incidents served to highlight critical gaps in the regulatory framework governing assisted reproductive technologies – and the system has had to step up.
In these cases, parents who believed they were receiving a particular donor’s sperm have discovered, often through genetic testing, that their children are not biologically related as intended.
A decade on from The Toft Report, these legacy incidents – which prompted calls for stricter quality control measures, improved tracking systems, and greater transparency within the fertility industry – are the UK’s backbone for prioritising rigour, helping to prevent such mistakes and ensure trust and safety for patients and donors undergoing fertility treatment.
Nevada lawsuit, 2023
A shocking lawsuit filed in Nevada reignited concerns about the safety and reliability of US procedures. A father and daughter from Las Vegas took legal action against a fertility doctor, an embryologist, and related clinic staff after a DNA test allegedly revealed that they were not biologically related.
The lawsuit, filed in Clark County District Court on September 30, 2023, details how the father and his now-deceased wife sought fertility treatment in 2004 at Nevada Fertility C.A.R.E.S., a clinic led by Dr Rachel McConnell. The couple had selected an egg donor and expected the embryo to be created using the father’s sperm. Under the care of embryologist Dee Harris, an embryo was implanted, leading to the birth of their daughter in October 2006.
However, the family’s world was turned upside down when the daughter took a DNA test through Ancestry.com in 2023, only to discover that her father was not her biological parent. The father now has no information on what happened to the embryo that was supposed to have been created using his sperm.
The lawsuit accuses McConnell and her team of reckless negligence, claiming their actions represented a severe departure from standard IVF care, leading to significant emotional distress for both father and daughter.
In a particularly heartbreaking revelation, the lawsuit states that the father and daughter must now undergo legal adoption proceedings to formalize their parent-child relationship, an emotionally and financially burdensome process.
“The problem at the end of the day is that we believe that the meticulous protocols that should have been followed were not,” said the family’s attorneys at Murdock and Associates in a statement.
The case raises serious ethical and medical concerns about fertility treatments and the importance of strict protocols to prevent devastating errors. It also highlights the ongoing legal and emotional challenges faced by families affected by IVF mishaps, further emphasizing the need for greater oversight in the industry.
As of now, neither McConnell nor Harris has responded to the allegations, and the father and daughter have chosen to remain anonymous as they pursue legal justice.
Your to-do list
Keen to learn more? The HFEA is packed with information, which you can cross-check with your clinic or treatment provider if you’re unsure. Let us know too, if you have a question or query – we’re super-quick to respond in our Insta DMs.
