An IVF baby was born with cystic fibrosis after its parents were mistakenly identified as not being carriers of the condition, according to a report.
The Human Fertilisation and Embryology Authority (HFEA) said the grade A incident, the most severe, took place after screening results from a pathology laboratory were not properly read by the treating clinician, and were not signed and transposed into the patients’ medical records.
The case was detailed in the HFEA’s first “state of the sector” report, which contained largely positive news about IVF in the UK.
It said the number of women who have twins, triplets or more following IVF treatment has reduced from nearly one in four in 2009 to one in 10, described as a “fantastic” achievement which has increased the safety of the procedure for mothers and babies.
The drop in multiple births has also reduced the burden on NHS antenatal and neonatal services, the Government’s independent regulator overseeing fertility treatment and research said.
But it added that “some areas for concern” included that the number of reported adverse incidents increased last year, from 497 in 2015 to 540.
Of these, 325 were categorised as grade C and 176 were grade B, with just the one grade A incident in 2016.
Other findings from that incident were that there was no robust system providing evidence that reports are reviewed by the treating clinician or nurse before being filed.
The clinic, which was not named, did not have a standard operating procedure to ensure reports are allocated to the appropriate member of staff for review.
It added that changes have been implemented since.
The HFEA said that through working with licensed clinics in the UK, it has reduced the national multiple birth rate from 24% in 2009 to 11%. This has come without a reduction in birth or pregnancy rates, with the latter rising from 24% in 2008 to 32%.
Multiple births are the greatest risk associated with fertility treatment.
At least half of twins are born premature and underweight, which can lead to serious health problems and even death.
Mothers are far more likely to have an early or late miscarriage if they are carrying multiple babies and are more likely to suffer from health problems such as high blood pressure, gestational diabetes, anaemia and haemorrhage.
More than 76,000 cycles of IVF were carried out in 119 licensed fertility clinics across the UK in 2016/17.
Three in five treatments (60%) were paid for by patients themselves.
There are 132 treatment and research clinics working under licence in the UK, of which 34% are privately run, 29% are in public/private partnership, and 22% are NHS only, according to the report. The remaining 15% are research only.
NHS Choices estimates that around one in seven couples in the UK have trouble conceiving, around 3.5 million people.
IVF success rates depend on how old the woman is, ranging from 32.2% of treatments resulting in a live birth for women under the age of 35 in 2010, to just 5% for women aged 43 to 44.
The National Institute for Health and Care Excellence (Nice) recommends eligible patients should have access to three rounds of IVF funded through the NHS, but just 12% of local health bodies offer this many cycles. Others offer one or two cycles and some offer none at all.
Costs vary but they can be around £5,000 for one cycle.
HFEA chairwoman Sally Cheshire said the report “outlines the importance of us working together to ensure patients, donors and the donor-conceived get the highest possible quality care”.