Small bowel obstruction and perforation after Essure sterilization: a case report

Could the anatomic location of Essure® device explain the impairment of quality of life?

BACKGROUND

Since health-related quality of life (HRQL) could improve after removal of Essure^® (Bayer, Leverkusen, Germany) inserts in symptomatic patients, we aimed to assess whether such postoperative enhancement was linked to the anatomic placement of the device.

METHODS

Correct and incorrect placed Essure^® (Bayer) were identified in the electronic database of the French cohort Ablimco (cohort of consenting patients with laparoscopic Essure^® [Bayer] removal). HRQL, pain and heavy menstrual bleeding were evaluated after Essure^® (Bayer) removal with validated quality of life questionnaires (Short Form12 Questionnaire, Visual Analogue Scale, French version of the McGill Pain Questionnaire and the pictorial blood assessment chart PBAC).

RESULTS

Sixty-five patients were included in the study divided in two groups (group A with correct placement: 45 patients and group B with incorrect placement: 20 patients). HRQL and Pain Index were improved in both groups at 6 months post-surgery. There was not any statistically significant difference between group A and B. The PBAC score increased at 6 months postoperatively in group A and B without any statistically significant difference between them.

CONCLUSIONS

Postoperative improvement of quality of life and pain index was similar whatever the position of the implant. This suggests that symptomatology and quality of life are not related to the anatomic location of the Essure^® (Bayer) implants.

Laparoscopic Removal of a Retroperitoneal Hysteroscopic Microinsert Using Fluoroscopy

Perforation during placement of hysteroscopic microinserts for permanent sterilization occurs in approximately .9% to 2.6% of women undergoing the procedure. Most of the time perforation results in intraperitoneal placement of the hysteroscopic microinsert requiring laparoscopy or laparotomy for removal of the device. Herein we present a case of hysteroscopic microinsert perforation with subsequent retroperitoneal identification of the device. This is the first such case to our knowledge of retroperitoneal identification and retrieval of a perforated device that required real-time fluoroscopy during laparoscopy.

High miscarriage rate in women treated with Essure® for hydrosalpinx before embryo transfer: a systematic review and meta-analysis

OBJECTIVES

Essure® has been tested as an alternative treatment for hydrosalpinx before embryo transfer (ET) in women undergoing assisted reproduction techniques. However, the persistence of a foreign body inside the uterine cavity might have a negative impact on the outcome of pregnancy. The present systematic review aimed at identifying, appraising and summarizing the available evidence regarding the effectiveness and safety of using Essure prior to ET for women with hydrosalpinx.

METHODS

We searched for studies in PubMed, Scopus, CENTRAL, Web of Science and ClinicalTrials.gov and the reference lists of eligible studies. All studies including at least 10 women with hydrosalpinx who received Essure, any other intervention or no treatment prior to ET were considered eligible. Study selection, data extraction and evaluation of the risk of bias were performed independently by two authors. Study outcomes were miscarriage per clinical pregnancy, singleton preterm birth per singleton live birth and live birth/ongoing pregnancy and clinical pregnancy per ET. The pooled results for each outcome and intervention were summarized as proportions with their respective 95% CIs, using a random-effects model.

RESULTS

Our electronic search of databases was performed on 7 November 2015, and 26 studies with 43 study arms were considered eligible: eight study arms evaluating Essure; seven assessing tubal aspiration; seven appraising effects of no treatment; 12 evaluating salpingectomy; two assessing tubal division; and seven evaluating tubal occlusion. When compared with women who had no intervention, women with Essure had a higher clinical pregnancy rate per ET (36% (95% CI, 0-43%) vs 13% (95% CI, 9-17%)). When compared with women who had other interventions, women with Essure had a higher miscarriage rate per clinical pregnancy (38% (95% CI, 27-49%) vs 15% (95% CI, 10-19%)).

CONCLUSIONS

The available evidence suggests that, although Essure prior to ET in women with hydrosalpinx improves the chance of achieving a clinical pregnancy compared with no intervention, it is associated with a higher rate of miscarriage when compared with the other interventions. Although this evidence is based on observational studies, we believe that salpingectomy should be the first option for women who are eligible for videolaparoscopy. However, it is still premature to make recommendations for women who are not eligible for surgery, and randomized controlled trials are needed to clarify which is the best treatment alternative in such a scenario. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Essure Microinsert Abdominal Migration after Hysteroscopic Tubal Sterilization of an Appropriately Placed Essure Device: Dual Case Reports and Review of the Literature

Background. The Essure device is a method of permanent sterilization widely used in the US that has proven to be safe and effective in most cases. However, there have been reports of device migration that have led to failed tubal occlusion as well as several other serious complications resulting from the presence of the device in the abdominal cavity. Case. This paper represents two cases of failed tubal occlusion by an appropriately placed Essure device without signs or symptoms of further complications related to device migration. Conclusion. Although there have only been 13 reported cases of abdominal device migration since November 2014, this case indicates that the actual number may be higher than reported since it is possible for migration to occur without additional complications. In the majority of reported cases of abdominal migration a major complication requiring surgical correction occurred, such as adhesions, small bowel obstruction, bowel perforation, or persistent pelvic pain. To avoid these complications it is recommended that migrating implants be removed; however, this case also represents an example of when a migrating device may remain in situ in an asymptomatic patient.

Bowel perforation after placement of tubal occlusion contraceptive

BACKGROUND

The tubal occlusion contraceptive provides a hysteroscopic technique for female sterilization. Efficacy of the tubal occlusion contraceptive relies on proper placement within the proximal aspect of the fallopian tubes. As long-term data become available, rates of complications are better defined.

CASE

This is a case of a patient who underwent placement of a tubal occlusion contraceptive. As a result of persistent pain and nausea, imaging was performed and malposition of the tubal occlusion contraceptive was identified. During laparoscopy, bowel perforation at the terminal ileum was diagnosed. Laparoscopic ileocecectomy was performed.

CONCLUSION

There should be a low threshold for evaluation of complications after tubal occlusion contraceptive placement. Although rare, bowel perforation after placement of the tubal occlusion contraceptive can occur. Laparoscopic management should be considered.

Management of perforated essure with migration into small and large bowel mesentery

The Essure permanent birth control system (Conceptus Inc, San Carlos, CA) is currently the only Food and Drug Administration-approved hysteroscopic sterilization method and has been widely accepted as a safe and effective procedure. We present a rare case of tubal perforation, coil fragmentation, and distal migration into small and large bowel mesentery 8 days after the insertion of the Essure device. We describe the successful management of this complication using laparoscopy and intraoperative fluoroscopy. Providers using Essure must be aware of the possibility of fragmentation of the Essure coils. Intraoperative imaging, ideally fluoroscopy, should be strongly considered in the management of Essure migration to ensure localization and full retrieval of Essure material.

Risk of Essure microinsert abdominal migration: case report and review of literature

Purpose

To report a case of Essure microinsert abdominal migration and literature review.

Methods

A 41-year-old woman was counseled to undergo Essure sterilization. The procedure was hampered by the presence of endometrial cavity adhesions, obscuring left tubal ostium. By using microscissors the adhesions were progressively lysed. Since the procedure had become very painful, the patient required general anesthesia. Once adhesion lysis was completed, the tubal ostium was well visible. Both devices were then easily introduced into the fallopian tubes. At the end of the procedure, five coils were visible on the right side and five coils on the left side, as recommended.

Results

The 3-month hysterosalpingogram follow-up suspected abdominal migration of the left device. Laparoscopy confirmed the device displacement in the left lower abdominal quadrant. Both fallopian tubes and the uterus appeared normal. No signs of perforation were detected. The device was embedded into the omentum, but it was easily removed. Bilateral tubal sterilization was performed by bipolar coagulation.

Conclusion

There are only 13 cases, including the present, of Essure abdominal migration in the literature. In most cases, abdominal displacement of the microinsert is asymptomatic and does not induce tissue damage. However, in some cases, it may cause a severe adverse event, requiring major surgery. Therefore, removal of the migrated device should be performed as soon as possible. Moreover, during presterilization counseling, the patient should also be correctly informed about the risk of this rare but relevant complication, as well as about the surgical interventions that could be required to solve it.

Tubal sterilization: pregnancy rates after hysteroscopic versus laparoscopic sterilization in France, 2006-2010

OBJECTIVE

To compare the rates of pregnancy among women who underwent Essure hysteroscopic sterilization versus tubal ligation in France between 2006 and 2010.

STUDY DESIGN

Retrospective cohort study.

SETTING

Hospital care in France (nationwide). Anonymised database of all hospital discharge summaries in France.

PATIENTS

Recruitment was based on procedure codes in the national database of hospital discharge summaries. The study included all women who underwent tubal sterilization by Essure microinserts or by tubal ligation and subsequently were hospitalised either for all unexpected pregnancies related diagnosis (e.g., miscarriage, legal abortion, or delivery) or for pregnancies following reversal microsurgery or invitro fertilization (IVF) treatment.

MEASUREMENTS AND MAIN RESULTS

During the study period, French hospitals performed 109,277 tubal sterilization procedures: 39,169 Essure sterilizations and 70,108 laparoscopic tubal ligations. The respective indication of both techniques depended on the surgeons' skill. The median age of the two populations was similar, 41 years (range 28-52) for Essure patients and 40 years (range 27-54) for those undergoing tubal ligation (p=0.42). A Cox model has been performed. Following sterilization, after adjustment on age Essure patients became pregnant at a significantly lower rate than laparoscopic ligation patients 0.36% versus 0.46%, respectively (HR=0.62 (040-096)), and their pregnancy rate of post-sterilization procedure was significantly lower (reversal microsurgeries: 0.02% versus 0.19% (p<0.001), IVF treatment: 0.08% versus 0.27%) (p<0.001). The pregnancy rates after IVF were 12.5% and 5.35%, respectively, and 0% and 11.36% after tubal repair.

CONCLUSION

This nationwide study of tubal sterilization demonstrates that Essure was associated with lower rates of pregnancy versus tubal ligation.