If your plan covers infertility, you may want to review your coverage for the next procedure that is being covered commercially: the uterine transplant.
This procedure may be discussed when a member has uterine factor infertility. She may have been born without a uterus, a condition known as uterine agenesis. Of 15 to 40-year-old women, approximately 9000 cases are known, per Dr. Paige Porrett of the University of Alabama at Birmingham. In addition, Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome is a rare congenital disorder that affects the female reproductive system. This condition is characterized by an underdeveloped vagina and uterus. The uterus may be small or absent and the vagina is typically shortened. These women are usually not able to carry a pregnancy and they may be able to have children through assisted reproductive services. MRKH Syndrome affects approximately one in 4500 females, per the National Institutes of Health. Another 31,000 women lose their uterus to benign indications. Overall, it is estimated that roughly 5% of women are affected by uterine factor infertility.
Prior to uterine transplant, surrogacy was the only option. Historically, the first live birth from a uterine transplant was through a clinical trial in Gothenberg, Sweden, in 2014. Globally, there have been approximately 120-130 transplants resulting in approximately 60 live births.
Uterine transplants are categorized as Vascularized Composite Allotransplants (VAC). This category also includes hand and face transplants. These are considered life enhancing rather than their life-saving counterparts that include heart, lung, and liver transplants.
There are several eligibility requirements and exclusions to the procedure which vary by program. These normally include an age range of 20 to 40 and being genetically female (XX chromosome). The procedure begins with a medical examination and evaluation that lasts approximately two to three days. Next, embryos are created through in-vitro fertilization (IVF) and cryopreserved for implantation, and genetic testing is performed on the embryos.
The woman then prepares for the uterus transplant surgery. The donor uterus may come from a living or deceased donor and is handled like all organ transplants through the Organ Procurement and Transplantation Network (OPTN). Immunosuppression is given in the OR and the donor uterus is transplanted. The patient will need to continue to take immunosuppressants as long as the donor uterus is in place.
There are approximately three to six months from evaluation to transplant. Extended stays close to the hospital for monitoring may be required throughout this process.
To allow for healing, there are another three to six months between the transplant surgery and embryo transfer. The standard of care is to transplant one embryo at a time. This involves one night in the ICU and an average of one-week inpatient hospitalization.
If the embryo successfully implants in the uterus and pregnancy is achieved, the patient then continues to be monitored and followed as a high-risk pregnancy. If pregnancy is not achieved, another attempt will follow in a month. If the pregnancy progresses without complications a Cesarean section (C/S) is performed at 37 wks. The uterus may stay intact if additional pregnancies are planned or may be removed at time of C/S. The longest a uterus has remained transplanted is five years. It is not meant to be a permanent transplant; rather, it is intended only to be temporary to achieve pregnancy and childbirth.
Risks
Graft loss of 25-30%. Infection, and renal compromise. The miscarriage rate is the same as women with their own biological uterus. There is a six-fold increase in pre-eclampsia, an increase in gestational diabetes, and an increase in growth restriction of the fetus noted and due to the immunosuppression. Uterine transplants also increase the risk of premature birth. The earliest births in US programs have been at thirty weeks gestation. There are approximately ten years of data on children born through uterine transplant; to date, the children are developmentally normal.
Cost
Estimates range from $250,000 – $500,000 for all phases, with the timeline stretching as long as 15+ months from evaluation to delivery. Many patients have had the benefit of research funding, and some patients have had institutional financial support. Some patients have paid out of pocket. Some programs have commercial insurance coverage.
Programs
Cleveland Clinic, Baylor, University of Pennsylvania, Johns Hopkins, University of Alabama-Birmingham. The University of Alabama-Birmingham has had 41 uterus transplants with 26 live births. This represents approximately 40% of the global number.
In some states there are legal issues to consider. In Alabama for example, IVF was stopped as of 2/27/24 due to state laws which are now being litigated.
This is a rare condition with a rare solution. For those benefit plans that cover infertility, it would be prudent to review your benefit coverage and any limitations.
Article written by Ginny Fisher, RN, BSN, Managed Care Specialist for Summit Reinsurance Services, Inc. For more information about how this may affect your plan, please contact your Summit ReSources managed care specialist. The following sources were used as reference material for this article:
National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10477946/
https://jamanetwork.com/journals/jamasurgery/fullarticle/2793976