Human error caused IVF mix-up 
Source: AsiaOne 24 Nov 2010
INVESTIGATIONS into a botched in-vitro fertilisation (IVF) procedure at Thomson Medical Centre (TMC) concluded that it was due to lapses in procedure and human error.
Investigators found that TMC’s IVF centre had deviated from standard operating procedures, said Minister for Health Khaw Boon Wan, who shared his ministry’s audit results yesterday.
Earlier this month, it was reported that the Thomson Fertility Centre, a subsidiary of TMC, had wrongly used another man’s sperm to conceive a child for a couple – a Singaporean Chinese woman and her Caucasian permanent- resident husband.
After the incident, the Ministry of Health (MOH) ran a check on nine other assisted reproduction centres here.
Besides TMC, two other centres were found to have deviated from international best practices.
Mr Khaw revealed three key lapses that led to the mix-up:
Firstly, the embryologist was processing the semen specimens of two individuals at the same workstation, and at the same time.
Best practice requires an embryologist to work on the specimens of only one individual or one couple at a time.
Secondly, the pipette used to transfer the specimen was reused instead of being discarded.
To prevent contamination and a potential mix-up, the disposable instrument should have been discarded after each step.
Mr Khaw said: “Even though it was reused only for handling the specimens from the same individual, it unnecessarily raised the risk of human error.”
Finally, the third major lapse was the absence of a second operator to counter-check that the specimens were transferred to the correct receptacles.
“This incident has no doubt impacted the reputation of Thomson Medical Centre IVF Centre and also indirectly affected Singapore’s reputation as a regional medical hub,” said Mr Khaw.
He also addressed queries by Dr Lam Pin Min, a Member of Parliament for Ang Mo Kio GRC, about the rights of the unintended father in the case.
He said that TMC has a duty towards every individual involved in this incident and that the baby’s “rights should take priority”.
“If the donor asks, then TMC will have a duty to inform but TMC should not volunteer information, taking into account the impact it might have, especially on the baby,” he said.
He added that the Health Ministry is not aware of any other mix-ups in recent years.
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