Abstract
OBJECTIVES: This study aims to systematically review the economic evaluations of various embryo transfer strategies, including single embryo transfer (SET), double embryo transfer (DET) and others in IVF. METHODS: Web of Science, Scopus, PubMed, Embase, and the NHS Economic Evaluation Database were searched since January 1980 to 1 October 2023. Full economic evaluations comparing embryo transfer strategies were included; while review articles, editorials, abstracts, and non-English articles were excluded. The CHEERS 2022 checklist was used to assess the quality of the included studies. FINDINGS: Out of 4,336 records, 16 studies were included, mostly from Europe (75%), with a few from North America (19%) and Asia (6%). Most studies (94%) assessed the cost-effectiveness of SET versus DET using cost-effectiveness analysis (CEA), one study (6%) used cost-utility analysis (CUA). The Markov model was most common, with some using decision-tree or other modeling approaches. Study perspectives were societal (50%), healthcare system (25%), service provider (12.5%), or insurer (12.5%). The most reported outcomes were live birth rate (50%) and incremental cost per live birth (56%), while other outcomes, such as expected life years or quality-adjusted life years were less frequently reported. CONCLUSION: Findings indicate that SET and SET-based strategies, such as combining fresh and frozen SET cycles or mild stimulation protocols, are often more cost-effective than DET and other strategies, especially among younger women, by reducing maternal and neonatal complications and long-term healthcare costs. Cost-effectiveness, however, varies by maternal age, healthcare system context, modeling approach, patient preferences, and societal willingness-to-pay thresholds. Most evidence comes from high-income countries, but the findings provide insights to guide evidence-based embryo transfer decisions that balance clinical effectiveness, patient preferences, and economic sustainability.