Twins of mixed races: consequences for Dutch IVF laboratories

In June 1995, people working in the field of in-vitro fertilization (IVF) were startled by newspaper reports mentioning the birth of an IVF twin of mixed races. What has been thought of as the ‘nightmare of the embryologist’ had actually happened in a busy IVF setting of the Academic Hospital in Utrecht, The Netherlands. The unfortunate event gave rise to a whole series of questions: how are the parents of the twins going to live with it, how are the children going to cope with it and also, of course, what went wrong in the IVF laboratory and what measures have to be taken to further minimize such kind of risks. In the Dutch Society for Clinical Embryologists a discussion on quality assurance and safety has been opened and will lead to practical consequences for Dutch IVF laboratories. Apart from letting it be a national debate, we felt it would be appropriate to inform IVF laboratories more widely. An inquiry into the scientific literature on the subject of ‘gamete exchange in IVF9 did not provide us with any publication although in the lay press misuse of gametes in other occasions was reported. In a review on donor insemination (Linden t al., 1995), however, mislabelling or mishandling of gametes is mentioned as a potential risk factor and a few examples are discussed. The recommendations of the safety and standards committee of the European Society of Human Reproduction and Embryology (ESHRE) stresses the importance of good labelling for the identification of specimens, according to good laboratory practice, and labels should bear the names of the patient (ESHRE, 1991). However, no further details or specific requirements are given. It is the purpose of this communication to report the incident in Utrecht to our international colleagues and open a discussion about safeguarding in our work, assuming that similar incidents can occur elsewhere or even have occurred elsewhere, maybe even going without notice.