Cost-effectiveness Analysis of Uterus Transplantation versus Gestational Carrier for Treatment of Absolute Uterine Factor Infertility

Jessica R Walter; Elliott G Richards; Liza Johannesson; Tommaso Falcone; Giuliano Testa; Kathleen E O'Neill; Heidi S Harvie

doi:10.1016/j.fertnstert.2025.01.010

Cost-effectiveness Analysis of Uterus Transplantation versus Gestational Carrier for Treatment of Absolute Uterine Factor Infertility

Fertil Steril. 2025 Jan 21:S0015-0282(25)00035-4. doi: 10.1016/j.fertnstert.2025.01.010. Online ahead of print.

Authors

Jessica R Walter¹, Elliott G Richards², Liza Johannesson³, Tommaso Falcone², Giuliano Testa³, Kathleen E O'Neill⁴, Heidi S Harvie⁵

Affiliations

¹ Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL. Electronic address: jessica.walter@northwestern.edu.
² Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH.
³ Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX.
⁴ Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
⁵ The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA.

PMID: 39848423
DOI: 10.1016/j.fertnstert.2025.01.010

Abstract

Importance: Patients with uterine factor infertility (UFI) have few options for family building. Uterus transplant is a feasible treatment for some patients; however, cost remains a significant concern.

Objective: To compare the cost effectiveness of treatment for patients with absolute uterine factor infertility to achieve 1-2 singleton births by gestational carrier or uterus transplant DESIGN: Decision analysis from the United States healthcare sector perspective, with time horizons to achieve one or two singleton births.

Intervention: Gestational carrier or uterus transplant MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratios, comparing the costs (2020 U.S. Dollars) and effectiveness (quality-adjusted life years, QALYs, and live births) to achieve one or two births by gestational carrier and uterus transplant.

Results: In the base case of one singleton birth, the overall cost using a gestational carrier was $97,712.90 ($56,985.20-$153084.20) compared $116,137.20 ($67,142.88-$182,290.86) after uterus transplant. QALYs were higher in the gestational carrier arm (0.93) compared to uterus transplant (0.90) and overall rates of live birth were also higher in the gestational carrier arm (94%) compared to the uterus transplant arm (77%). Costs of the gestational carrier and uterus transplant recipient were the most significant cost variables in the model. Monte Carlo simulation showed that uterus transplant had a 37% chance of being the cost-effective strategy for a single live birth at a willingness to pay of $150,000/QALY. In the case of two singleton births, the cost using a gestational carrier was $186,278.56 ($103,597.81-$296,010.27) compared to $164,276.84 ($111,961.91-$229,394.43) after uterus transplant. QALYs were again higher in the gestational carrier arm (0.93) compared to uterus transplant (0.89). Overall rates of two live birth were also higher in the gestational carrier arm (86%) compared to the uterus transplant arm (66%). Monte Carlo simulation showed that uterine transplant has a 62% chance of being the cost-effective strategy for two live births at a willingness to pay of $150,000/QALY.

Conclusion: Treatment of uterine factor infertility with a gestational carrier is likely the most cost-effective approach for patients delivering a single child. However, the absolute costs associated uterus transplant were 14% less than a gestational carrier for those having two live singleton births.

Keywords: cost-effectiveness analysis; gestational carrier; uterine factor infertility; uterus transplant.