Teaser:

On September 24, 2019, Daphna Cardinale gave birth to the beautiful baby girl she and her husband Alexander had been dreaming of. This was their second child, and they, along with their four-year-old daughter Olivia, were all excited to be welcoming this new little life. Her arrival had been eagerly anticipated even from before her conception, but especially once she was a tiny, living embryo waiting to be transferred to Daphna’s uterus during a routine in vitro fertilization (IVF) procedure. Alexander told ABC News that with this pregnancy, they envisioned their family being complete.

Daphna shared that her baby’s birth “was this moment of sheer bliss when everybody was getting to know each other and falling in love with each other. She just really folded into our lives and into our hearts.”

Alexander Cardinale: “Getting to know this newborn daughter and bringing Olivia in to meet her and the two of us getting to know this baby and falling in love with her – everything was great.” 

Except everything was not “great.” While he was feeling love for his new baby girl, Alexander also harbored another feeling – a terrible feeling in his gut that he could not seem to shake. When he looked at his baby whom he had waited so long to hold, he was taken aback by her appearance, which he would later describe as “jarring.”  He explained that when he first laid eyes on her, “The room shrank, and I got really dizzy … and everything just went numb. I stayed in that place for a long time.”

What was it about this baby girl whom his wife had just given birth to that stopped Alexander in his tracks? What could possibly have made him react so severely that he backed several feet away from the baby until his back was against the wall? And why did he seem to be the only one who noticed?

Podcast Intro:

You’re listening to Conceiving Crime, the podcast dedicated to Investigating crimes past and present involving sex, procreation, pregnancy, birth, and all things human reproduction. I’m your host, Sami Parker. See the full show notes & links to resources from this episode at ConceivingCrime.com.

Act I: - Growing their Family

In the summer of 2018, Daphna and Alexander first met with Dr. Eliran Mor at the LA-based California Center for Reproductive Health, and had decided, based on the fertility doctor’s advice, to try IVF to grow their family. But this road to having another baby was going to have its challenges. Daphna would spend weeks administering drugs to her body by needle as often as five times a day to hyper-stimulate her ovaries into producing multiple eggs – as many as 20 – in one cycle. She visited the fertility clinic every other day for exams and blood tests. Eventually, her eggs were retrieved and fertilized in the lab using Alexander’s sperm. Daphna and Alexander said they told the fertility clinic that they planned to have every embryo that was created transferred to Daphna’s uterus. But they were told there was only one embryo considered to be both viable and chromosomally normal. That embryo was transferred to Daphna’s uterus in October of 2018, but sadly, the baby did not survive. 

Though heartbroken, Daphna started the process over again, and the second round of IVF again produced one embryo who was deemed to be the only usable one. Daphna, Alexander, and their daughter, Olivia were thrilled when they learned that Daphna was pregnant, but the pregnancy was not without its struggles of nausea, discomfort, and other concerns. Yet, believing this pregnancy was likely to be Daphna’s last, the family spent those next nine months delighting in the very existence of this new life and imagining a joy-filled future as a family of four. Olivia would talk to her baby sister in her mother’s womb, telling her how she loved her and how she would help take care of her. When at long last, their baby girl finally made her debut outside the womb in September of 2019, Alexander, as he would later describe the significance of the day to People Magazine, called it “one of the happiest moments of our lives.”

But while Daphna and young Olivia bonded with the new baby, Alexander felt something was off with the little girl. He admitted that he had a “primal reaction” to who it was the baby looked like and he told CBS Evening News: 

Alexander Cardinale:“I had a weird, sort of a gut reaction when she was born. It wasn’t anything logical. It was just like an instinct.”

Seeing his innocent baby girl “was so jarring” to Alexander that he “actually took several steps away from the birthing table, backing up against the wall” when he first saw her. With her dark hair, she didn’t look like their fair-haired preschool-aged first-born daughter Olivia, but the baby was not completely dissimilar in appearance to her mother Daphna at that age, who was also born with jet black hair. Combined with the fact that his wife had carried this baby for nine months and given birth to her, it should have been enough to convince Alexander that there was nothing to be concerned about. And he tried to ignore his feelings. After all, did it matter what color hair his daughter had or who his daughter looked like? Should these things matter to a parent? But as much as he tried to ignore his fears, he was constantly looking them in the face. It wasn’t just that the baby’s hair was dark. Her complexion was darker than the rest of the family’s as well.

Once home together, the family settled into the routines of life. But Alexander still could not let his concerns go. The questions that nagged him about his baby’s appearance began to frustrate Daphna. And soon, friends were making comments about the baby’s appearance as well. Eager to quiet the chatter about her daughter, Daphna bought an at-home DNA test. 

She had carried and birthed this baby who felt so familiar to her that it didn’t occur to her that anything could be amiss. She hoped the DNA test would put everyone’s questions to rest and they could finally move on with their lives as a happy family of four. But, Alexander would later mark the taking of that DNA test as the moment their world “started falling apart.”

It was November now and their baby girl was two months old when the couple received the results of the DNA test in an email which declared that their infant daughter was not genetically related – to either of them. 

Act II: - Background

The first successful attempt at IVF took place in 1977 and resulted in the birth of Louise Brown on July 25, 1978. Within the next six months, two more babies were born after being conceived via IVF. Today, 2.3% of all babies born in the US are created using artificial reproductive technologies including IVF. 

Fertility has grown into a billion-dollar industry that profits from the desperation of people who understandably want so badly to be parents. One round of IVF alone costs an average of $23,000 and carries just a 20-30% rate of success. Behind every live birth from IVF, there are typically countless human embryos who don’t survive the process. They are either destroyed for not meeting industry standards, frozen indefinitely, or die during defrosting or implantation efforts. Research shows that if just one embryo is created during each IVF cycle (the average is seven embryos), at least 80% — that’s at least two million — of the human beings created through IVF die.

The fertility industry thrives on the mentality that any adult who wants a child deserves to have a child. But IVF does not come without risks for the women involved or for the children who do survive to be born. 

A British study noted that for women, assisted reproductive technologies involve exposure to multiple carcinogens and carry the risk of breast, endometrial, and ovarian cancers. There have also been recent headlines declaring that IVF is nothing more than a “cash cow” for fertility doctors, who don’t bother to find the source of a couple’s infertility struggles or offer them more affordable and more effective options.

Children created through IVF have an increased risk of low birth weight, premature birth, hospital admission, perinatal mortality, cerebral palsy, and significantly increased risk of birth defects compared to children conceived naturally. They are also at risk for high blood pressure, and girls conceived through IVF sometimes have advanced bone age and hormonal imbalances during puberty. In addition, some studies show an increased risk of childhood illnesses including an elevated risk of cardiovascular problems, early-onset acute lymphoblastic leukemia, an increased risk of cancer in general, cognitive impairment, and other health concerns. 

 And while IVF is often referred to as emotionally taxing for the adults involved, there are psychological and emotional concerns for the children as well. When they learn about the circumstances of their conception, some feel like a consumer product, which makes sense considering the underlying eugenic principles of the fertility industry.

Embryos created through IVF are labeled by a grading system determined by how likely they are to survive – as was true with the Cardinales’ embryos of which one was deemed to be viable. They are also assigned designations, reducing these children to items on a factory line rather than the unique individuals that they are. Classifying human beings based on their perceived health is a form of eugenics. So is choosing embryos based on their sex, which is gaining popularity among the elite. A survey published by the Journal of Assisted Reproduction and Genetics found that about 73% of U.S. fertility clinics offer gender selection. 

Dr. Alan Copperman, the chief executive of RMA of New York, a fertility business, recently told The New York Times that he is seeing more wealthy couples skipping sex and going straight to IVF to have a baby. Some do it because they say they are too busy to conceive naturally while others have reproductive goals they want to achieve – such as having a specific gender. Other couples want to screen their children for health conditions and then weed out the ones who don’t make the cut. If you’ve seen the 1997 film Gattaca starring Ethan Hawke and Uma Thurman, you know where this is headed. 

The fertility industry is its own Wild West with a severe lack of regulations which leaves the door open for major mistakes with life-altering consequences to occur – like the one the Cardinales were about to experience.

Act III: - Switched Before Birth

Shocked and confused at the results of their DNA test, Alexander and Daphna had no idea why their daughter wasn’t related to them and they were afraid that the baby girl they loved so much would be taken away. Every knock on the door struck fear in Daphna’s heart. 

Daphna Cardinale: “When I found out she wasn’t mine, I poured more love into her. I don’t know. Maybe I was just clinging to her. But I was just so scared I was going to lose her, which I ultimately did.:

The couple learned that Daphna had been implanted with a stranger’s embryo and had given birth to a baby girl who wasn’t biologically hers, but whom she loved and was attached to. But she wondered – what had become of the other embryo – her embryo?

Unsure of what the next step should be, Alexander and Daphna hired attorney Alex Wolf to help them investigate how such an error had happened and to help them learn if they may have a biological child out in the world whom they needed to find. 

Could another woman be pregnant with their baby unknowingly? Was their embryo still frozen in a lab? Was their child out there in the world somewhere without them – and would they ever find her?

The day after Thanksgiving, the couple’s attorney contacted the California Center for Reproductive Health and Dr. Mor, informing them of the situation. The couple learned that their embryo was no longer at the lab, but they didn’t know what had happened to her. Their child was missing. Then they learned that the fertility company believed that their embryo may have been mixed up with the embryo of another couple when the embryology lab, In VitroTech (which is also owned by Dr. Mor), was taking biopsies of the embryos to send for genetic testing. The DNA test the Cardinales had done on themselves and the baby allowed for the biological parents of the baby girl to be located. That couple, who had also undergone IVF at the California Center for Reproductive Health, had also delivered a baby in the same time frame – but that didn’t mean that she was the Cardinales’ baby. This second baby girl could have been a second biological embryo of the same couple or perhaps even the baby of a third couple.

Daphna: “We found the parents so we lost our birth baby and there’s another baby that could potentially be our baby but could potentially be their baby or someone else’s baby.

Alexander: “Because they could have had more than one embryo so maybe it was just their other embryo so we were just in hell that week. That was a week of hell.”

The full story began to unravel for Daphna and Alexander when it was discovered that the other baby was not biologically related to the other couple. Could this baby be the biological child of Alexander and Daphna? And, if so, would they ever meet her? 

Within days, Alexander and Daphna were staring at the photo of a blonde-haired, blue-eyed baby girl named Zoë. They suspected immediately that this baby was their biological daughter and it wasn’t long before a DNA test confirmed it. On Christmas Eve, it was officially determined that their biological embryo had indeed been swapped with the embryo of strangers, and on December 26, the day after the babies’ first Christmas, they reached out to those strangers for the first time, unsure of the events that were about to unfold, but hopeful they would be reunited with their daughter. Thankfully, the other couple was experiencing similar feelings and concerns and were on the same page as the Cardinales. They wanted to meet their biological child too. 

On New Year’s Eve, Daphna and Alexander met their biological daughter Zoë for the first time in an attorney’s office, and the other couple, who wish to remain nameless, legally agreed to swap the girls back. But, in order to legally obtain custody of their own child, both women had to sign gestational surrogate contracts and formalize the exchange of babies. It was as though they had both been unwilling and unknowing surrogates for each other. Putting the agreement on paper was one thing – but actually switching the babies back was another, and it felt like an impossible situation to Daphna and Alexander.

Alexander recalled that during that first emotional reunion, the moment he picked up Zoë, he felt a “powerful and unexpected” feeling overcome him. “I knew this child,” he said. “At the same time, Daphna and I were so devastated and sad… about losing our birth daughter.” 

For Daphna, the emotional pain of giving up one daughter and welcoming another was devastating. 

Daphna: “With my birth daughter, I knew her, I carried her, I nursed her her whole life but Zoë I didn’t know. I didn’t know what she felt like, I didn’t know what she smelled like. I was just trying to learn her as quickly as I could, but she wasn’t familiar.”

While modern support for surrogacy would have us believe that carrying a child for nine months is inconsequential, the truth is, that a deep bond forms between mother and child during this time. Daphna and the baby girl she carried were – in every way but biological – mother and child. Studies show that taking a baby from her birth mother — whether she is biologically related to her or not — causes immense trauma for the baby and can permanently alter a child’s adult brain function later in life. It was Daphna’s voice, smell, and heartbeat that the baby girl knew. It was Daphna who was her mother, her safe place. As much as it hurt Daphna to give up this baby, it hurt the baby to be separated from Daphna – only the baby couldn’t rationalize such a loss.

But what else could be done? The wheels were now in motion to swap the babies back. When the Cardinales finally told little Olivia, too young to fully understand, she begged her parents not to switch the babies. They were torn. They didn’t want to say goodbye to the daughter they had been raising but they wanted to know, love, bond with, and raise the baby girl who was biologically their daughter. They couldn’t keep both babies.

The Cardinales spent the next few heart-wrenching weeks meeting with the other couple, who lived just ten minutes away, almost daily, and exchanging the baby girls for brief visits so that they could slowly bond with and become comfortable with their biological families. Then, when the constant switching had become too much, they permanently switched the baby girls to be back with their biological parents on January 17, 2020, 114 days after Daphna had given birth. This change marked the beginning of what they call “the darkest time of their lives” from January through March of 2020. After the switch, five-year-old Olivia began having breakdowns. She missed the baby sister she had bonded with as did Daphna and Alexander. And the couple was overcome with guilt that they had essentially given her away – traded the baby who knew only them as her parents for another baby who had also been ripped from the only family she had known.

Daphna: “Her birth will always be tainted by the sick reality that our biological child was given to someone else and the baby that I fought to bring into this world was not mine to keep. The daughter we raised and bonded with was gone after months of love and affection. There’s no way to describe the pain that we’ve been through, the struggle to guide our older daughter in losing the little sister she fell in love with.”

It was a situation with no winners – only traumatized families trying to navigate the most difficult circumstances of their lives while causing as little emotional damage to the children as possible.

The couples continued to see each other and spend time with both babies, but then, the COVID-19 pandemic hit. For six weeks, Daphna, Alexander, and Olivia didn’t see the baby Daphna had given birth to. They struggled to bond with Zoë amid their heartache and Daphna cried every night. 

As time went on, the families stayed in close contact with each other, celebrating birthdays and holidays and building their own unique version of a blended family. 

Then came the lawsuit, which ushered in massive media attention. In November 2021, two years after the ordeal had begun, the world began to learn the story of the babies switched before birth, and the fertility industry would face well-deserved scrutiny regarding its complete lack of regulations. How could a mistake like this happen? And if it happened to the Cardinales, how often was it happening to other families?

The Cardinales filed a lawsuit against the California Center for Reproductive Health, Dr. Mor, Beverly Sunset Surgical Associates LLC, and In VitroTech Labs Inc. for medical malpractice, negligence, fraud, breach of contract, breach of implied covenant of good faith and fair dealing, battery, and more. The lawsuit sought unspecified damages. Attorneys for the fertility businesses said the lawsuit should be dismissed, in part, because there were not enough details to support all of the Cardinales’ claims. The fertility clinic’s attorneys argued, "There is no credible allegation that Dr. Mor was aware the embryo he transferred to Daphna Cardinale had been mislabeled or mixed up and was not her embryo.” But why wasn’t he aware of how the embryos in the care of his business were being handled?

Eventually, in June 2022, the Cardinales settled the case, but no details of the settlement were made available. They had their biological daughter and a relationship with their birth daughter, but so much damage had been done, and that trauma will linger with them for the rest of their lives. How it affected Zoë and the other baby has yet to be seen. 

Conclusion: A history of mix-ups    

Unfortunately, the Cardinales are not the only parents left to deal with the aftermath of an embryo mix-up during an IVF procedure. In April of 2022, it was revealed that a woman had been implanted with a stranger’s embryo by the New York Fertility Institute, which wasn’t the first time this fertility clinic had made such a mistake. In this case, the parents ran genetic testing during pregnancy to rule out any chromosomal abnormalities in the baby, but the test results showed that the woman was not related to the baby she was carrying and an amniocentesis confirmed this. The New York Fertility Institute denied that there was a mix-up, but the woman and her husband shockingly decided to abort the healthy baby at six months despite claiming they had “grown to love this baby, who had already begun kicking.” According to reports, they did not want to lose her even if she was not genetically related to them, while on the other hand, they couldn’t imagine carrying a stranger’s baby to term only to lose her in a legal battle later. It was a horrific case of “if we can’t have her, no one can” that led to the intentional killing of an innocent child. It is unknown if the baby’s biological parents ever learned of their child’s heartbreaking fate.

In a 2009 case, an Ohio woman learned the baby she was carrying was not her biological child but she did not abort the baby. After the birth, she gave the child back to its biological mother. "We're trying to look at it as a gift for another family that eight months ago we didn't know," she said. "We will wonder about this child every day for the rest of our life." She is unaware of what happened to her own embryos, who could not be located.

In a 2019 case, a woman in New York gave birth to two babies who were not related to her but were the biological children of two completely different couples. Two different embryos from two different couples had been transferred to her uterus and she and her husband were forced to give those babies to their biological parents.  

Also in 2019, a couple learned that their 12-year-old son was not biologically related to the husband when they took 23andMe genetic tests as a fun family activity. It turned out, the fertility clinic had used the wrong man’s sperm when creating the couple’s embryos.

It’s hard to imagine that the Cardinales were the lucky ones in an embryo mix-up. But they were. Their daughter was alive. She had not been destroyed as an embryo and she had successfully grown in another woman’s uterus. No one had aborted her and they were able to get her back while also maintaining a relationship with the daughter they were forced to give up. But their story, and each of the others like it, highlights the lack of regulations in the fertility industry, a lack of respect for human life, and a hypocritical aspect of the world of fertility treatments and IVF – biology only seems to matter when the adults want it to. 

The use of sperm donors, egg donors, and surrogates is increasing in the fertility industry so that adults can create a baby by any means necessary. These methods of creating new life are celebrated in the media, but the children who are created through them aren’t so jubilant about it. Sixty-two percent of children conceived through donor technologies, including surrogacy, believe it to be an unethical and immoral practice. They feel like business transactions. These children are created with the intention of separating them from one or both of their biological parents, unlike adoption, which exists to heal a wound created when the biological parents are unable to care for the child. In adoption, the child is the client and isn’t viewed as property or a prize that an adult is entitled to; they are human beings. Today, 95% of private adoptions are open because having that connection is now understood to be what’s best for the child. This proves that adoptive parents are aware that the biological connection matters. But with donor conception and surrogacy, whether an egg donor or sperm donor is used for a married man and woman to have a baby or for a gay couple to have a baby, the child always loses because she is created to be taken away from her biological parent on purpose and grows up being told that knowing and being loved by her missing biological parent or parents does not matter. She’s told that being wanted by the adults raising her should be enough. Yet, when it’s the parents who want the biological connection, biology matters deeply and they feel they have the right to a biological child at any cost.

One young man who was created through traditional surrogacy – in which the birth mother is also the egg donor – explained that his birth mother was paid $8,000 to have him and give him away. He said, “Something horrible happened to us at birth. We lost our mothers. They did not die, but they might as well have been dead because we lost them in the capacity of mother, and to a tiny baby, that feels like death…That makes us feel very rejected. That leaves a hole in our hearts whether we admit to it or it manifests some other way like in depression or a fear of getting close to someone else…”

“I wanted my mother,” he said, “and she wasn’t there.”

It remains to be seen what the long-term effects of the trauma the Cardinale family suffered will be and how it will especially affect the innocent children – both Olivia and Zoë and the other baby. But they expect the damage will be lifelong.

“This is something that’s just changed who we are,” said Daphna. “It’s still a daily struggle and will continue to be.”