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Jeirath N, Basinski CM, Hammond MA. Hysteroscopic Sterilization Device Follow-Up Rate: Hysterosalpingogram Versus Transvaginal Ultrasound. J Minim Invasive Gynecol 2018; 25:836-841. [PMID: 29289623 DOI: 10.1016/j.jmig.2017.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/15/2017] [Accepted: 12/22/2017] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To assess if follow-up confirmation testing 3 months after hysteroscopic sterilization with the Essure device (Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ) improved with recommendation for transvaginal ultrasound (TVUS) versus hysterosalpingogram (HSG). DESIGN Retrospective, observational case-controlled cohort study (Canadian Task Force classification II-2). SETTING Two-physician private practice in Evansville, Indiana. PATIENTS Compliance rates for a TVUS confirmation test on 100 women who underwent hysteroscopic sterilization compared with a previously published cohort of 1004 women who were scheduled to undergo an HSG confirmation test. INTERVENTION Acquisition of 3-month confirmation testing after Essure hysteroscopic sterilization. MEASUREMENT AND MAIN RESULTS All women who underwent Essure hysteroscopic sterilization with recommendation for TVUS confirmation testing between July 2015 and January 2017 were compared with a previously published cohort of 1004 patients with recommendation for HSG confirmation testing (HSG cohort). In addition, an HSG subgroup cohort (HSG subgroup) similar in size and closest chronology to the TVUS cohort was drawn from the original 1004 patients and analyzed for HSG follow-up. Records for all patients were reviewed for demographic, procedural, and confirmation testing and outcome data. One hundred patients were identified with successful Essure device placement and a recommendation for TVUS confirmation testing. Eighty-eight patients (88.0%) returned for TVUS at 3 months. In the HSG cohort 1004 successful Essure devices were placed, and 778 patients returned for the recommended HSG follow-up (77.5%). There was a significantly higher follow-up rate for TVUS compared with the HSG cohort (88.0% vs 77.5%, p = .008). In the HSG subgroup 184 patients were identified, and 133 patients presented for HSG follow-up (72.3%), indicating a significantly higher follow-up rate in the TVUS cohort (88.0% vs 72.3%, p = .001). No pregnancies after any confirmation testing were noted. CONCLUSION Confirmation testing with TVUS rather than HSG 3 months after Essure device placement results in increased patient compliance that may lead to improved patient outcomes with reduction of unintended pregnancy.
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Affiliation(s)
- Neha Jeirath
- Department of OB/GYN Indiana University School of Medicine, Indianapolis, Indiana; Basinski and Juran, MDs, LLC, Newburgh, Indiana
| | | | - Max A Hammond
- Department of Biomedical Engineering, Purdue University, West Lafayette, Indiana
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Antoun L, Smith P, Gupta JK, Clark TJ. The feasibility, safety, and effectiveness of hysteroscopic sterilization compared with laparoscopic sterilization. Am J Obstet Gynecol 2017; 217:570.e1-570.e6. [PMID: 28757140 DOI: 10.1016/j.ajog.2017.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND In contrast to conventional laparoscopic sterilization, newer hysteroscopic approaches avoid the need for hospital admission, general anesthesia, and prolonged recovery. However, there are concerns that the feasibility, safety, and efficacy of hysteroscopic sterilization may be lower than established laparoscopic sterilization. OBJECTIVE We sought to evaluate the outcomes of hysteroscopic sterilization compared with laparoscopic sterilization in routine clinical practice in a comparative observational cohort study. STUDY DESIGN This study was carried out at University of Birmingham, United Kingdom, National Health Service teaching hospital, office hysteroscopy clinics, and day-case hospital unit. In all, 1085 women underwent hysteroscopic sterilization and 2412 had laparoscopic sterilization. Hysteroscopic sterilization was carried out using the tubal implant permanent birth control system in the office setting and laparoscopic sterilization using the tubal ligation system as a day-case under general anesthesia. Outcome data were collected regarding feasibility (technical completion of the sterilization procedure, satisfactory radiological confirmation at 3 months-hysterosalpingogram or transvaginal pelvic ultrasound scan), safety events within 30 days of procedures, reoperations, and unintended pregnancies within 1 year of procedures. RESULTS Hysteroscopic sterilization was successful in 992/1085 (91.4%; 95% confidence interval, 89.6-93.0%) at the first attempt. In comparison, bilateral tubal ligation was successfully performed in 2400/2412 (99.5%; 95% confidence interval, 99.2-99.8%) of patients who underwent laparoscopic sterilizations (odds ratio, 18.8; 95% confidence interval, 10.2-34.4). In all, 902/1085 (83.1%; 95% confidence interval, 80.8-85.2%) of successfully performed hysteroscopic procedures attended for radiological confirmation testing were considered satisfactory. The rate of adverse events within 30 days were similar: 2/1085 (0.2%) vs 3 (0.12%; 95% confidence interval, 0.04-0.36%). There were 3/1085 (0.3%; 95% confidence interval, 0.1-0.8%) unintended pregnancies after hysteroscopic sterilization compared with 5/2412 (0.2%; 95% confidence interval, 0.1-0.5%) laparoscopic sterilization (odds ratio, 1.3; 95% confidence interval, 0.3-5.6). Median length of follow-up for pregnancy outcome was 5 years. Hysteroscopic sterilization was associated with a higher risk of reoperation at 1 year compared to laparoscopic sterilization (odds ratio, 6.2; 95% confidence interval, 2.8-14.0) and the commonest reintervention was unilateral salpingectomy (12/22, 54.5%). CONCLUSION Hysteroscopic sterilization has been introduced as a more convenient, office-based method of permanent fertility control. However, while the small risk of unintended pregnancy is comparable to conventional laparoscopic sterilization, women should also be counselled regarding its lower success rate in successfully completing the procedure and its higher rate of failed reoperation.
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Affiliation(s)
- Lina Antoun
- Specialist Registrar, Birmingham Women's National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Paul Smith
- Birmingham Women's National Health Service Foundation Trust, Birmingham, United Kingdom; School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Janesh K Gupta
- Birmingham Women's National Health Service Foundation Trust, Birmingham, United Kingdom; Academic Department of Gynecology, Birmingham's Women's and Children's Hospital, University of Birmingham, Birmingham, United Kingdom; University of Birmingham, Birmingham, United Kingdom
| | - T Justin Clark
- Birmingham Women's National Health Service Foundation Trust, Birmingham, United Kingdom; Academic Department of Gynecology, Birmingham's Women's and Children's Hospital, University of Birmingham, Birmingham, United Kingdom; University of Birmingham, Birmingham, United Kingdom.
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VanBuren WM, Suchet IB, Thiel JA, Karreman E. Essure microinsert imaging: does abnormal shape on ultrasound predict complications on HSG? Abdom Radiol (NY) 2016; 41:2350-2358. [PMID: 27022912 DOI: 10.1007/s00261-016-0718-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We hypothesize that the shape of the Essure microinsert on ultrasound is able to predict complications evident on hysterosalpingogram (HSG), the accepted gold standard. METHOD AND MATERIALS From July 2, 2009 to July 2, 2012, 441 women at our institution received Essure microinsert placement for the purpose of permanent sterilization. 2D and 3D coronal plane transvaginal ultrasounds were performed three months after Essure microinsert placement. Those patients with complications identified on ultrasound, a non-diagnostic ultrasound, or following a difficult insertion were referred for HSG. Patients with both HSG and ultrasound performed were retrospectively selected and anonymized. The ultrasounds were reviewed by a single, blinded radiologist. A total of 122 microinserts in 65 patients were described on ultrasound using a numeric grading system and compared to HSG findings. RESULTS Microinsert placement resulted in 37 complications, 31 of which were identified on ultrasound, including uterine and tubal perforations and placement in the endometrial cavity. The sensitivity of Essure microinsert shape on ultrasound in predicting complications, compared with standard HSG, was 94%, with a positive predictive value of 85%; specificity was 95%, with a negative predictive value of 98%. The Kappa coefficient was 0.85 (p < 0.001). CONCLUSION Our results suggest that ultrasound may be used as a frontline imaging modality for patients after Essure microinsert placement.
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Virginia Hu YH, Arora KS. Improving Rates of Post-Essure Hysterosalpingography in an Urban Population Using Electronic Tracking Reminders. J Minim Invasive Gynecol 2016; 24:305-308. [PMID: 27867049 DOI: 10.1016/j.jmig.2016.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/05/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To demonstrate the efficacy of electronic reminders for follow-up hysterosalpingography (HSG) after Essure hysteroscopic sterilization in an urban tertiary care hospital obstetrics and gynecology practice. DESIGN Retrospective cohort study (Canadian Task Force classification II-3). SETTING Obstetrics and gynecology practice at a university-affiliated urban tertiary care teaching hospital. PATIENTS Two hundred and fifty patients who underwent Essure hysteroscopic sterilization between June 2011 and July 2014. INTERVENTION Implementation of electronic reminders for the office staff. MEASUREMENTS AND MAIN RESULTS Two hundred and fifty of 259 patients (96.5%) underwent Essure hysteroscopic sterilization and successful placement of coils into bilateral Fallopian tubes. Among these 250 patients, 135 (54%) returned for HSG at 3 months post-Essure as advised at the time of procedure. The use of electronic reminders prompted another 45 patients (18%) to return for HSG, improving the total post-Essure follow-up rate to 72%. CONCLUSION Electronic reminders for the office staff of an urban tertiary care hospital's obstetrics and gynecology practice is an effective method for improving the rate of post-Essure HSG.
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Affiliation(s)
- Yu-Han Virginia Hu
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
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Basinski CM, Juran RS, Fein A. Essure© Sterilization: Experience and Outcomes with 1024 Patients in a Solo Practice Over 8 Years. J Gynecol Surg 2016. [DOI: 10.1089/gyn.2015.0103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Contraceptive failure after hysteroscopic sterilization: Analysis of clinical and demographic data from 103 unplanned pregnancies. Obstet Gynecol Sci 2015; 58:487-93. [PMID: 26623413 PMCID: PMC4663227 DOI: 10.5468/ogs.2015.58.6.487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/06/2015] [Accepted: 07/06/2015] [Indexed: 11/11/2022] Open
Abstract
Objective This investigation examined data on unplanned pregnancies following hysteroscopic sterilization (HS). Methods A confidential questionnaire was used to collect data from women with medically confirmed pregnancy (n=103) registered after undergoing HS. Results Mean (±SD) patient age and body mass index (BMI) were 29.5±4.6 years and 27.7±6.1 kg/m2, respectively. Peak pregnancy incidence was reported at 10 months after HS, although <3% of unplanned pregnancies occurred within the first three months following HS. Mean (±SD) interval between HS and pregnancy was 19.6±14.9 (range, 2 to 84) months. Patients age ≥30 years and BMI <25 reported conception after HS somewhat sooner than younger patients, although the differences in time to pregnancy were not significant (P=0.24 and 0.09, respectively). The recommended post-HS hysterosalpingogram (to confirm proper placement and bilateral tubal occlusion) was obtained by 66% (68/103) of respondents. Conclusion This report is the first to provide patient-derived data on contraceptive failures after HS. While adherence to backup contraception 3 months after HS can be poor, many unintended pregnancies with HS occur long after the interval when alternate contraceptive is required. Many patients who obtain HS appear to ignore the manufacturer's guidance regarding the post-procedure hysterosalpingogram to confirm proper device placement, although limited insurance coverage likely contributes to this problem. The greatest number of unplanned pregnancies occurred 10 months after HS, but some unplanned pregnancies were reported up to 7 years later. Age, BMI, or surgical history are unlikely to predict contraceptive failure with HS. Further follow-up studies are planned to capture additional data on this issue.
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Chudnoff SG, Nichols JE, Levie M. Hysteroscopic Essure Inserts for Permanent Contraception: Extended Follow-Up Results of a Phase III Multicenter International Study. J Minim Invasive Gynecol 2015; 22:951-60. [DOI: 10.1016/j.jmig.2015.04.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/16/2015] [Accepted: 04/19/2015] [Indexed: 10/23/2022]
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Moureau D, Laurent N, Rubod C, Lucot JP, Salleron J, Faye N. Evaluation of tubal microinserts position using 3D ultrasound and pelvic X-ray. Diagn Interv Imaging 2015; 96:1133-40. [PMID: 26163222 DOI: 10.1016/j.diii.2014.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 04/30/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE To retrospectively compare three-dimensional ultrasonography (3D-US) and pelvic X-rays to assess the position of tubal sterilization microinserts. MATERIAL AND METHODS Forty-four patients who underwent tubal sterilization with Essure(®) microinserts in our institution were included. The microinserts'position was evaluated three months after the procedure using 3D-US and pelvic X-rays. Placement on 3D-US was binary categorized as correct or incorrect and the distance between the two devices was reported. The orientation and symmetric deployment of the microinserts and the distance between the proximal parts of the two devices was assessed on pelvic X-rays. Performance of 3D-US and pelvic X-ray were compared using Mac Nemar test. Comparison of the distance between the two devices measured on pelvic X-rays and 3D-US was made with the paired Student t test. RESULTS 3D-US images showed microinserts in 93% (41/44). Eighty-six percent (38/44) were correctly positioned on 3D-US and 82% (36/44) on pelvic X-rays. No significant differences between the performances of the two imaging techniques were found. No significant differences for the distance between the two devices measured on pelvic X-ray and 3D-US was found. CONCLUSION 3D-US is a simple, non-ionizing technique, which appears as a promising alternate technique to pelvic X-rays to assess the correct position of Essure(®) microinserts.
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Affiliation(s)
- D Moureau
- Women Medical Imaging Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France.
| | - N Laurent
- Women Medical Imaging Department, Valenciennes Hospital, Lille Nord University, Valenciennes, France
| | - C Rubod
- Gynecology Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France
| | - J P Lucot
- Gynecology Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France
| | - J Salleron
- Department of Biostatistics, EA2694, UDSL, Lille University, Lille, France
| | - N Faye
- Women Medical Imaging Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France
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Ouzounelli M, Reaven NL. Essure Hysteroscopic Sterilization Versus Interval Laparoscopic Bilateral Tubal Ligation: A Comparative Effectiveness Review. J Minim Invasive Gynecol 2015; 22:342-52. [DOI: 10.1016/j.jmig.2014.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/18/2014] [Accepted: 12/02/2014] [Indexed: 12/01/2022]
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Mahmud S, Pereira N, Taylor KC, Ekbladh LE. Improving adherence to hysterosalpingography after hysteroscopic sterilization using an electronic reminder. J Minim Invasive Gynecol 2014; 22:250-4. [PMID: 25452046 DOI: 10.1016/j.jmig.2014.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/10/2014] [Accepted: 10/11/2014] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE The US package labeling of the Essure system (Bayer Healthcare, Whippany, NJ) requires hysterosalpingography (HSG) as a confirmatory test after hysteroscopic sterilization to ensure proper placement and tubal occlusion. Previous studies have shown that implementation of a protocol to track patients after Essure procedures can improve HSG adherence. The primary objective of this study was to investigate whether implementation of an electronic reminder for the office staff increases post-Essure HSG adherence. DESIGN Retrospective cohort study of patients who underwent the Essure procedure between January 2005 and January 2012 (Canadian Task Force classification II-3). SETTING University-affiliated hospital. PATIENTS Two hundred eleven patients underwent the Essure procedure during the study period. INTERVENTIONS Implementation of an electronic reminder for the office staff. MEASUREMENTS AND MAIN RESULTS One hundred thirty-seven (64.9%) patients underwent the procedure before implementation of the electronic reminder, and 74 (35.1%) patients underwent the procedure after implementation. Although the odds of post-Essure HSG adherence increased in the overall (odds ratio [OR] = 1.7; 95% confidence interval [CI], .9-3.2) and faculty practice (OR = 2.1; 95% CI, .2-18.6) patient population, these results were not statistically significant. In contrast, the odds of post-Essure HSG adherence increased by almost 3-fold (OR = 2.9; 95% CI, 1.4-6.3) in the resident clinic patient population (p = .003). CONCLUSION Implementation of an electronic reminder increases post-Essure HSG adherence in the resident clinic patient population.
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Affiliation(s)
- Semhar Mahmud
- Obstetrics and Gynecology Healthcare Associates, Riddle Hospital, Media, Pennsylvania
| | - Nigel Pereira
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania.
| | - Katherine C Taylor
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Lamar E Ekbladh
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Hysteroscopic Sterilization: 10-Year Retrospective Analysis of Worldwide Pregnancy Reports. J Minim Invasive Gynecol 2014; 21:245-51. [DOI: 10.1016/j.jmig.2013.09.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 09/25/2013] [Accepted: 09/26/2013] [Indexed: 11/18/2022]
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Leyser-Whalen O, Berenson AB. Adherence to hysterosalpingogram appointments following hysteroscopic sterilization among low-income women. Contraception 2013; 88:697-9. [PMID: 24012097 DOI: 10.1016/j.contraception.2013.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 07/11/2013] [Accepted: 07/26/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The few studies on post-Essure hysterosalpingogram (HSG) adherence rates show inconsistent results. This study examined associations between sociodemographic variables not examined in prior studies and HSG adherence among low-income women. STUDY DESIGN Medical records of 286 women who underwent sterilization between August 31, 2005, and September 30, 2011, were reviewed. chi-Square and Mann-Whitney U tests were used to determine variable associations with HSG adherence. RESULTS The adherence rate for the first HSG was 85.0% (243/286). Variables associated with adherence were lower education level (p=.01), not working outside the home (p=.04), being married (p<.0001), lower gravidity (p=.03), fewer lifetime number of sexual partners (p<.0001), no sexually transmitted infection history (p<.01), Hispanic ethnicity (p<.0001), Spanish as a primary language (p<.0001) and living farther from the clinic (p<.01). CONCLUSIONS This study demonstrates that achieving high rates of adherence with the recommended HSG following Essure placement is feasible among low income populations. Furthermore, not speaking English or having to commute a far distance to the clinic do not appear to be barriers. This is encouraging considering the importance of this test to confirm tubal occlusion.
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Affiliation(s)
- Ophra Leyser-Whalen
- Department of Sociology and Anthropology, University of Texas at El Paso, El Paso, TX 79968, USA.
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Howard DL, Wall J, Strickland JL. What are the Factors Predictive of Hysterosalpingogram Compliance After Female Sterilization by the Essure Procedure in a Publicly Insured Population? Matern Child Health J 2012; 17:1760-7. [DOI: 10.1007/s10995-012-1195-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Contraception permanente par pose hystéroscopique d’implants tubaires. ACTA ACUST UNITED AC 2012; 40:434-44. [DOI: 10.1016/j.gyobfe.2012.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 04/10/2012] [Indexed: 11/20/2022]
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Strandell A. Is the 3D-US technique the future method of choice to accompany hysteroscopic sterilization to reassure women of a reliable birth control method? Hum Reprod 2011; 26:2681-2. [PMID: 21846729 DOI: 10.1093/humrep/der244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Female sterilisation is a safe and effective form of permanent birth control. In the United States (US), it is still the second most commonly used form of contraception overall and is the most frequently used method among married women and among women over 30 years of age. Although several European countries have noted a sharp decline in the number of women electing tubal sterilisation in recent years, such trends have not been as obvious in the US. While female sterilisation remains popular, there are considerable system-level barriers to getting the procedure for certain segments of the population as well as emerging concerns about appropriate utilisation of this contraceptive method in light of newer, reversible options and the knowledge that regret after permanent contraception is high. Given the complexity of this decision-making process, it is critical that providers ensure at the very least that women are aware of the potential disadvantages of tubal occlusion and are knowledgeable of other highly effective contraceptive methods that are available but vastly underutilised in the US, namely, vasectomy, intrauterine contraceptives, and implants.
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Affiliation(s)
- Nikki Zite
- Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, 37920, USA.
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