Comparing gestational carrier with uterine transplantation in uterine-factor infertility: a cost-effectiveness analysis.

Abstract

Objective: To compare the cost-effectiveness of a gestational carrier (GC) to a uterine transplantation (UTX) in the treatment of absolute uterine-factor infertility.

Design: We performed a cost-effectiveness analysis using a decision-tree mathematical model comparing a GC with a UTX.

Subjects: Published literature was used to derive costs for solid organ transplant, immunosuppression, GC obtainment, in vitro fertilization, preimplantation genetic testing, and frozen embryo transfer (FET).

Exposure: Gestational modality: GC or UTX. We assumed graft failures occurred immediately and FETs at least 6 months after transplant.

Main outcome measure(s): The primary outcomes were costs per live birth, number of children born, and quality-adjusted life years for each gestational modality.

Results: Uterine transplantation was more expensive than a GC by $1.4 million with a lower utility by 23.74 quality-adjusted life years using the same average number of children born per 2 FETs. After 10,000 simulated iterations, the GC arm had 2 children born 42% of the time, compared with only 17% of the time in the UTX arm. No children were born 56% of the time in the UTX arm vs. 16% for the GC arm. Deterministic and probabilistic sensitivity variance of all cost parameters by ±75% ($39,292-$275,044 for GC vs. $390,761-$2,735,329 for UTX) and other input parameters by ±20%, including graft failure (21%-31%) and live birth per embryo transfer (29%-78%), produced the same outcomes in >99% of scenarios simulated, as did variation in immunosuppression time (2-18 months) between delivery and subsequent FET. UTX was no longer absolutely dominated if the probability of a live birth per transfer using UTX increased beyond 85%, startup cost for UTX decreased to <$13,646.28, or GC costs increased to >$359,200.

Conclusions: Our model suggests that GC use is currently more cost effective than UTX for treating absolute uterine-factor infertility. However, the desire to carry one's own child is an intangible factor not captured in cost analyses, and improvements in UTX success rates or reduced costs may alter these results in the future.