In a notice posted to the ASX, the fertility giant said the incident took place on June 5 at its Clayton clinic in Melbourne.

It involved a patient’s own embryo being “incorrectly transferred” back to them, instead of an embryo from their partner.

However, the company noted the two incidents had taken place years apart, though Monash was only alerted to the older of the two in February this year.

Monash also said an internal investigation was underway, and promised immediate changes.

“Commencing immediately, Monash will implement interim additional verification processes and patient confirmation safeguards over and above normal practice and electronic witness systems, to ensure patients and clinicians have every confidence in its processes,” the statement read.

“Whilst industry-leading electronic witness systems have and are being rolled out across Monash IVF, there remains instances and circumstances whereby manual witnessing is required.”

Monash IVF also said it had reported the matter to the Reproductive Technology Accreditation Committee certifying body and the Victorian Health Regulator.