Detroit News: Book Details Embryo Mix-Up

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February 12, 2011 | Kim Kozlowski

Two medical professionals were to blame for a fertility clinic mix-up that led to an Ohio woman bearing the son of a Metro Detroit couple, according to a book that goes on sale Monday.

It took a clerk doing data entry to discover the error. But by then, it was too late.

The details are the first explanation of how a fertility clinic mixed up the frozen embryos of Macomb County residents Shannon and Paul Morell and transferred them to Carolyn Savage of Sylvania, Ohio.

The mix-up — which resonated across the country after Carolyn and Sean Savage had a son in September 2009 and then gave him to the Morells — is summarized in the epilogue of the Savages’ memoir, “Inconceivable,” previewed on Google Books. Although some experts say more information is needed, the Savages insisted on some explanation as part of their settlement with the still-unnamed fertility clinic.

“In our opinion, those responsible for the mistaken transfer include everyone involved in the process …,” wrote the Savages, who appeared Friday on NBC’s “Dateline.”

Sean Savage declined comment Friday, citing an embargo. But during the “Dateline” interview, he and Carolyn described the void they still feel since the mix-up, their decision to later use a surrogate to try to have another child, and how they would like the Morells’ son, Logan, to know “he was never a burden,” Carolyn said.

Shannon Morell, now raising 17-month-old Logan, said she’s grateful the error was detected.

“It’s hard to believe that somebody could be so careless when dealing with something so precious as human life,” Morell said. “I wonder how many times this has happened in the past, and people never found out.”

One fertility expert said the episode shows there needs to be more clinic transparency.

“I want for everyone in our field to know about this so we can double down and know this is one way to avoid this nightmare,” said Dr. Michael Mersol-Barg, president of the Michigan Society for Reproductive Endocrinology and Infertility.

The Savages had gone through in vitro fertilization and stored leftover embryos.

When they decided to have another baby, a clinic employee filled out a thaw order and forwarded it to the lab where their embryos were stored, according to the book. Labels were printed with identifying information. But they included an incorrect birth year for Carolyn, a clue that later helped uncover the mix-up.

According to the book, five days before Carolyn Savage saw her doctor, an embryologist looked at the thaw order. He turned to a binder with documents that indicated the exact location of all the fertility lab’s embryos in cryopreservation. The embryologist pulled an information sheet from the binder for Shannon Morell, who was listed in the lab under her maiden name, Shannon Savage. He then removed the Morells’ embryos from a tank. The Morells’ information sheet was placed in the back of the Savages’ file and the Savage name was written on the Petri dish.

“From that moment on, Shannon and Paul’s embryos were associated with Carolyn and my paperwork,” the Savages wrote. “If anyone had checked the Embryo Information Sheet in our (file), they would have found Shannon and Paul’s embryo information sheet.”

While the embryos thawed, the embryologist checked them and the labels against the identifying information in the file — but he did not check them against the information sheet in the file.

On the day Carolyn Savage had the transfer, the embryologist delivered three of the Morells’ embryos labeled with the Savages’ name to the doctor, with the file. But the doctor didn’t cross-check the embryos with the file, which had the wrong information sheet.

Nine days later, a clinic employee entering data into a computer of all embryo transfers from the previous two weeks noticed a discrepancy in Carolyn Savage’s birth year. The employee looked in the file and found the Morells’ information sheet.

The day after the mistake was found, the clinic changed its safety protocol to require more cross checks, the book says.

“The change was made too late for us,” the Savages wrote, “but fortunately not too late for future patients.”


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