ABSOLUTE UTERINE-FACTOR INFERTILITY - GESTATIONAL CARRIER OR UTERINE TRANSPLANT? – A COST EFFECTIVENESS ANALYSIS

To evaluate the cost effectiveness of gestational carrier (GC) versus uterine transplant (UTx) in absolute uterine-factor infertility (AUFI). A decision-tree mathematical model comparing GC versus UTx was created. Cost data for solid organ transplant (based on comparable procedure times), immunosuppression, gestational carrier obtainment, in vitro fertilization, preimplantation genetic testing, and frozen embryo transfer (FET) were obtained from published literature. Live birth rate per single, euploid FET (65% in the GC arm, 36% in the UTx arm) were derived from published data along with a 74% graft survival rate. FETs began six months after transplant and immunosuppression was assumed to be continuous based on existing transplant data in pregnancy. Average cost per live birth in each gestational modality was calculated for up to two FETs, as was the total average cost for two live births per arm. Sensitivity analyses were performed over a range of outcomes as well as procedural and treatment costs. GC use had the lowest average cost per live birth following initial transfer at $270,859 versus $5.82M for UTx. Cost equivalency for UTx versus GC was achieved if IVF costs increased to $3.62M per cycle or GC costs increased to $3.73M. Conversely, even if UTx added $0 in costs, equivalence could not be achieved. Following a second embryo transfer, GC remained the most cost-effective solution with an average cost per live birth of $211,474 versus $3.61M for UTx. Cost equivalency for UTx versus GC was achieved if IVF costs increased to $2.89M per cycle or GC costs increased to $3M. In a similar fashion, UTx equivalence could again not be achieved. If a second live birth is achieved from the same graft vs additional GC obtainment, GC remains the more cost-effective solution with a total average cost per two live births of $419,577 versus $5.12M for UTx. Variance in graft survival and live birth rate per transfer in each scenario did not alter the dominant solution. Our model, which reflects current U.S. healthcare costs for a highly complex solid organ transplant under ideal circumstances, suggests that a GC is more cost-effective than UTx in the treatment of AUFI. Future confirmation of these findings is needed as additional UTx clinical outcomes and cost data are published.