Tubal risk markers for failure to place transcervical sterilization coils

Results of the Insertion of Hysteroscopic Sterilization Devices in a Brazilian Public Hospital

OBJECTIVE

 To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility.

METHODS

 Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics.

RESULTS

 In 85.8% of the cases, the uterine cavity was normal, and the most commonly-described findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56 minutes (range: 1 to 10 minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%).

CONCLUSION

 Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

Factors Associated with Negative Patient Experiences with Essure Sterilization

Study Objective:

The objective of the study was to identify factors associated with negative patient experiences with Essure.

Design:

This was a retrospective cohort study and follow-up survey.

Setting:

The study was conducted in an academic setting.

Patients:

Patients included women who had an Essure placed between 2002 and 2017.

Methods:

The hospitals' database was queried to identify subjects and charts were reviewed to confirm medical information. Subjects were invited by mail, e-mail, or phone call to participate a survey regarding symptoms and satisfaction with Essure. A comparison was made between women who reported a negative experience with Essure versus those who did not. A multivariable logistic regression analysis was performed to identify subject or procedural characteristics associated with any negative experience with Essure sterilization.

Results:

Two hundred eighty-four women underwent Essure sterilization between 2002 and 2017, 42.3% of whom responded to the follow-up survey. Satisfaction with Essure was reported by 61.9% of respondents. Thirty-three percent of the respondents have undergone removal or desire removal of the device. The most frequent symptoms attributed to Essure were pelvic pain, dyspareunia, and vaginal bleeding. Forty-eight percent of the respondents were identified as having any negative experience with Essure. Factors associated with negative experiences with Essure included young age at placement (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.79–0.94; P < .001), high gravidity (OR 1.39; 95% CI 1.14–1.71; P = .002), and absent history of abdominal surgery (OR 0.35; 95% CI 0.12–1.00; P = .049).

Conclusion:

Young age at placement, high gravidity, and absent history of abdominal surgery are factors associated with negative patient experiences following Essure sterilization. A negative experience with Essure is common, although dissatisfaction with the device is not always attributable to symptoms. This information could be considered when counseling women who plan removal of Essure.

Implications Statement:

Our study provides new follow-up data with respect to hysteroscopic sterilization. This research is the first to examine any cause for negative patient experiences with Essure. Understanding factors associated with negative patient experiences could improve patient counseling regarding the extent to which symptoms could be attributed to Essure as well as counseling women who want to undergo removal of the device. These factors could in turn prove to be predictors for successful resolution of symptoms after removal of Essure. Results of this study could also be used for developing future hysteroscopic sterilization techniques.

Current techniques and outcomes in hysteroscopic sterilization: current evidence, considerations, and complications with hysteroscopic sterilization micro inserts

PURPOSE OF REVIEW

To describe the current data regarding effectiveness, complications, postoperative evaluation, and surgical interventions associated with Essure hysteroscopic sterilization.

RECENT FINDINGS

Hysteroscopic sterilization is a commonly performed procedure that is offered as a well tolerated, effective, outpatient method of permanent sterilization. Over the past several years, concerns have been raised regarding correct placement and postoperative complications. This has led to statements by both the Food and Drug Administration (FDA) in October, 2016 and American Association of Gynecologic Laparoscopists in February, 2017, as a significant portion of women seek removal of these devices. A current black-box warning issued by the FDA in 2016 recommends discussion of 'the probabilities of rates or events' of adverse outcomes associated with Essure placement.

SUMMARY

Although hysteroscopic sterilization is usually a safe, effective option for permanent contraception, new evidence regarding complications has emphasized the need for proper education and counseling. Appropriate patient selection and knowledge of potential complications is paramount to ensuring patients, and medical providers are well informed and have realistic expectations regarding potential placement and postoperative issues.

Intraoperative Factors that Predict the Successful Placement of Essure Microinserts

STUDY OBJECTIVE

To determine whether the number of coils visualized in the uterotubal junction at the end of hysteroscopic microinsert placement predicts successful tubal occlusion.

DESIGN

Cohort retrospective study (Canadian Task Force classification II-2).

SETTING

Department of obstetrics and gynecology in a teaching hospital.

PATIENTS

One hundred fifty-three women underwent tubal microinsert placement for permanent birth control from 2010 through 2014. The local institutional review board approved this study.

INTERVENTION

Three-dimensional transvaginal ultrasound (3D TVU) was routinely performed 3 months after hysteroscopic microinsert placement to check position in the fallopian tube.

MEASUREMENTS AND MAIN RESULTS

The correlation between the number of coils visible at the uterotubal junction at the end of the hysteroscopic microinsert placement procedure and the device position on the 3-month follow-up 3D TVU in 141 patients was evaluated. The analysis included 276 microinserts placed during hysteroscopy. The median number of coils visible after the hysteroscopic procedure was 4 (interquartile range, 3-5). Devices for 30 patients (21.3%) were incorrectly positioned according to the 3-month follow-up 3D TVU, and hysterosalpingography was recommended. In those patients the median number of coils was in both the right (interquartile range, 2-4) and left (interquartile range, 1-3) uterotubal junctions. The number of coils visible at the uterotubal junction at the end of the placement procedure was the only factor that predicted whether the microinsert was well positioned at the 3-month 3D TVU confirmation (odds ratio, .44; 95% confidence interval, .28-.63). When 5 or more coils were visible, no incorrectly placed microinsert could be seen on the follow-up 3D TVU; the negative predictive value was 100%. No pregnancies were reported.

CONCLUSION

The number of coils observed at the uterotubal junction at the time of microinsert placement should be considered a significant predictive factor of accurate and successful microinsert placement.

Outcomes of Elective Outpatient Hysteroscopic Sterilization in Undocumented Women: A Retrospective Analysis

OBJECTIVE

To determine the feasibility of hysteroscopic sterilization in low-income and unauthorized immigrant women when financial barriers to care are removed.

METHODS

Outpatient hysteroscopic sterilization for low-income women at an urban clinic was made possible by grant funding. All procedures were performed by obstetrician/gynecologist attending physicians or supervised trainees. Electronic records were reviewed for cases performed from June 2010 to December 11, 2013. Outcome incidences and complications were determined. Subgroup analyses using demographic and clinical factors were performed.

RESULTS

Hysteroscopic sterilization was attempted in 197 patients. Most were Hispanic (93%) and undocumented immigrants (83%). Bilateral placement was achieved on first attempt in 92% (181/197). Successful placement was ultimately achieved in 96% (190/197), and 88% (168/190) returned for hysterosalpingogram (HSG). Appropriate tubal occlusion was documented on 96% (161/168) of HSGs with mean time of 3.5 ± 1.3 months. Repeat HSG at 6 months showed 100% occlusion (7/7). Of the initial cohort, 85% (168/197) could ultimately rely on Essure for contraception. One pregnancy was self-reported 9 months after the procedure; the patient had not followed up for HSG. There were no pregnancies among those who completed follow-up. There were no cases of procedural complications. Successful Essure placement was not associated with age, parity, immigration status, or clinical characteristics (analgesics administered, history of cesarean section, vaginal delivery, cervical surgery, ectopic, fibroids, or pelvic inflammatory disease). The only factor positively associated with HSG follow-up was age 35 years or younger (53% vs. 47%; p = .03).

CONCLUSIONS

Successful hysteroscopic sterilization can be achieved in an undocumented, low-income population. Rates of confirmatory HSG follow-up were found to be higher than in the general population. Public funding of programs could decrease unintended pregnancies and pregnancy-related costs.

A Meta-Analysis of Bilateral Essure® Procedural Placement Success Rates on First Attempt

Background: The Essure® (Bayer HealthCare Pharmaceuticals, Leverkusen, Germany) female sterilization procedure entails using a hysteroscope to guide a microinsert into the Fallopian tube openings. Failed placement can lead to patient dissatisfaction, repeat procedures, unintended or ectopic pregnancy, perforation of internal organs, or need for subsequent medical interventions. Additional interventions increase women's health risks, and costs for patients and the health care industry. Demonstrated successful placement rates are 63%-100%. To date, there have not been any systematic analyses of variables associated with placement rates. Objectives: The aims of this review were: (1) to estimate the average rate of successful bilateral Essure microinsert placement on first attempt; and (2) to identify variables associated with successful placement. Materials and Methods: A meta-analysis was conducted on 64 published studies and 19 variables. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, all published studies between November 2001 and February 2015 were reviewed. The studies were taken from from PubMed and Google Scholar, and by using the the "snowball" method that reported variables associated with successful bilateral Essure placement rates. Results: The weighted average rate of successful bilateral microinsert placement on first attempt was 92% (0.92 [95% confidence interval: 0.904-0.931]). Variables associated with successful placements were: (1) newer device models; (2) higher body mass index; and (3) a higher percent of patients who received local anesthesia. Conclusions: The data gathered for this review indicate that the highest bilateral success rates may be obtained by utilizing the newest Essure device model with local anesthesia in heavier patients. More standardized data reporting in published Essure studies is recommended. (J GYNECOL SURG 31:308).

Control and constraint for low-income women choosing outpatient sterilization

Little is known about Hispanics and their contraceptive choices in general, with some past studies detailing nonconsensual sterilization. This article is based on interviews with a mostly Hispanic sample of 44 women being sterilized at a public clinic in southeast Texas with the Essure device, which entails a new outpatient sterilization procedure. The women cited relationship factors, wanting to better their and their children's lives, and past reproductive histories as reasons for deciding on sterilization. They specifically chose Essure as a result of an apprehension of surgery and potential side effects from tubal ligation. Their choices, however, were limited by larger structural factors of work, family, the political economy, and the health care system. We concluded that this new sterilization technique provided more contraceptive choices for these women, yet more contraceptive decision-making autonomy and more equitable social structures are still needed.