Milan IVF clinic mistakenly implants wrong embryo

A significant error has occurred at the San Raffaele assisted reproduction center in Milan, where medical staff mistakenly transferred the embryo of one couple to a woman belonging to another. The incident, which took place on July 23rd, has been attributed to "human error" by Enrico Papaleo, the head of the Assisted Reproduction Center, in an interview with Corriere della Sera.

The clinic is currently closed pending decisions from the relevant health authority. On the day of the incident, two embryo transfers were scheduled. In the Embryology laboratory, two biologists were preparing the embryos: one performed the procedure, and the second verified each step. Simultaneously, the patient was being identified in the preparation room by medical staff. According to reports, the lead biologist misread a program line and took the material for patient B from the incubator instead of patient A's. The second biologist confirmed the plates belonged to patient B, but the error had already occurred during the initial program reading, resulting in the embryo of one couple being transferred to the wrong woman.

The mistake was identified immediately after the procedure, and protocols were activated to manage the situation and protect those involved. San Raffaele, which is affiliated with the national health system, expressed its "deepest regret" and announced internal investigations involving the Ats and the National Transplant Center. The Embryology laboratory has been suspended by the competent authority for at least 15 days.

San Raffaele stated that corrective measures have been taken, and further controls will be implemented to enhance identification, verification, and traceability systems. The clinic noted that such incidents are estimated to occur once in every 10,000-12,000 assisted reproduction cycles globally. Both women involved, under 35 and in their first cycle, have been informed and are being monitored. One woman still carries her own embryo, while the other has scheduled a new cycle for the following month. Both have requested to continue their treatment at San Raffaele.