Tubal perforation by Essure: three different clinical presentations

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.

Essure microinsert imaging: does abnormal shape on ultrasound predict complications on HSG?

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.

[What signs should you look for ultrasound (2D/3D) to affirm the good location of tubal implants? About a retrospective study of 92 cases]

OBJECTIVE

The aim of this study is to propose an analysis of the route and the curvature of the Essure^® system in 3D ultrasound to determine their correct location so as not to miss a tubal perforation.

METHODS

This is a retrospective single center study during 2 years analyzing 92 3D ultrasound performed by a single sonographer. Implant placement was performed by different operators. One prescribed 3D ultrasound control in case of difficulties with the installation; other indications where systematics.

RESULTS

The Essure^®'s position is right in 79% of cases. Twenty-eight implants appear incorrectly positioned on ultrasound 3D positioning. Abnormalities found are those described by the classification proposed in the literature. In one case, the curvature of the implant, not taking into account this classification, allowed to evoke a tubal perforation. Among the 28 cases of non-visualized implants in place, 3 cases of wrong position of the implant were confirmed by additional examinations (laparoscopy or HSG). For 14 cases, the ASP or HSG disproved the wrong position of the implants. In other cases, we did not have other complementary examinations.

CONCLUSION

Ultrasonography 3D seems to be the method of choice to control implants for simple implementation and good reproducibility. However, the interpretation of 3D ultrasound images is sometimes difficult. The study of the curvature of the implant should be systematically analyzed not to miss a tubal perforation.

Discordant relationship between Essure microinsert position and tubal occlusion

Hysteroscopic sterilisation with Essure requires confirmation of tubal occlusion by hysterosalpingogram or microinsert position by transvaginal sonography 3 months after placement before women can rely on the method for pregnancy prevention. A 39-year-old woman underwent hysteroscopic sterilisation via Essure, with successful bilateral tubal occlusion documented on hysterosalpingogram. She had a subsequent unintended pregnancy and termination, and presented with persistent pelvic pain and other non-specific symptoms. She underwent a laparoscopic-assisted vaginal hysterectomy with bilateral salpingectomy, with complete resolution of her symptoms. Pathological evaluation demonstrated a perforated Essure microinsert and ipsilateral tubal occlusion, and a correctly placed Essure microinsert with ipsilateral tubal patency. Clinicians should be cautious about the assumption that correctly placed microinserts based on ultrasonography, hysterosalpingogram or laparoscopic evaluation assures occlusion success.

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).

Increasing Patient Engagement in Pharmacovigilance Through Online Community Outreach and Mobile Reporting Applications: An Analysis of Adverse Event Reporting for the Essure Device in the US

Background

Preparing and submitting a voluntary adverse event (AE) report to the US Food and Drug Administration (FDA) for a medical device typically takes 40 min. User-friendly Web and mobile reporting apps may increase efficiency. Further, coupled with strategies for direct patient involvement, patient engagement in AE reporting may be improved. In 2012, the FDA Center for Devices and Radiologic Health (CDRH) launched a free, public mobile AE reporting app, MedWatcher, for patients and clinicians. During the same year, a patient community on Facebook adopted the app to submit reports involving a hysteroscopic sterilization device, brand name Essure^®.

Methods

Patient community outreach was conducted to administrators of the group “Essure Problems” (approximately 18,000 members as of June 2015) to gather individual case safety reports (ICSRs). After agreeing on key reporting principles, group administrators encouraged members to report via the app. Semi-structured forms in the app mirrored fields of the MedWatch 3500 form. ICSRs were transmitted to CDRH via an electronic gateway, and anonymized versions were posted in the app. Data collected from May 11, 2013 to December 7, 2014 were analyzed. Narrative texts were coded by trained and certified MedDRA coders (version 17). Descriptive statistics and metrics, including VigiGrade completeness scores, were analyzed. Various incentives and motivations to report in the Facebook group were observed.

Results

The average Essure AE report took 11.4 min (±10) to complete. Submissions from 1349 women, average age 34 years, were analyzed. Serious events, including hospitalization, disability, and permanent damage after implantation, were reported by 1047 women (77.6 %). A total of 13,135 product–event pairs were reported, comprising 327 unique preferred terms, most frequently fatigue (n = 491), back pain (468), and pelvic pain (459). Important medical events (IMEs), most frequently mental impairment (142), device dislocation (108), and salpingectomy (62), were reported by 598 women (44.3 %). Other events of interest included loss of libido (n = 115); allergy to metals (109), primarily nickel; and alopecia (252). VigiGrade completeness scores were high, averaging 0.80 (±0.15). Reports received via the mobile app were considered “well documented” 55.9 % of the time, compared with an international average of 13 % for all medical products. On average, there were 15 times more reports submitted per month via the app with patient community support versus traditional pharmacovigilance portals.

Conclusions

Outreach via an online patient community, coupled with an easy-to-use app, allowed for rapid and detailed ICSRs to be submitted, with gains in efficiency. Two-way communication and public posting of narratives led to successful engagement within a Motivation-Incentive-Activation-Behavior framework, a conceptual model for successful crowdsourcing. Reports submitted by patients were considerably more complete than those submitted by physicians in routine spontaneous reports. Further research is needed to understand how biases operate differently from those of traditional pharmacovigilance.

Incidence of opioid-managed pelvic pain after hysteroscopic sterilization versus laparoscopic sterilization, US 2005-2012

OBJECTIVE

Compare incidence of opioid-managed pelvic pain within 12 months after hysteroscopic and laparoscopic sterilization.

METHODS

Using administrative claims, we identified women aged 18-49 years without recent history of childbirth who underwent hysteroscopic or laparoscopic sterilization between 2005 and 2012. We defined the outcome as ≥2 diagnoses for pelvic pain and ≥2 prescription fills for opioids. We calculated adjusted hazard ratios (HR) using Cox models and propensity score methods (matching and inverse-probability-of-treatment-weighting [IPTW]).

RESULTS

We identified 71,875 eligible women (hysteroscopic n = 26,927 [37.5%], laparoscopic n = 44,948 [62.5%]). Of those, 236 (0.88%) hysteroscopic patients and 420 (0.93%) laparoscopic patients experienced the outcome (crude HR = 0.97, 95%CI: [0.83, 1.14]). Adjusted analyses also yielded near-null results (matched HR = 1.08, 95%CI [0.90, 1.31]; IPTW HR = 0.97, 95%CI [0.80, 1.18]). While most sensitivity analyses generated results close to the null, hazard ratios estimated using propensity score matching ranged from 0.65 to 1.53.

CONCLUSIONS

Among women without recent history of childbirth, we did not find compelling evidence of a clinically meaningful increase in the incidence of pelvic pain requiring opioids during the year after hysteroscopic sterilization. However, effects observed in sensitivity analyses may merit further investigation.

Early hysteroscopic removal of intratubal microinserts with urologic stone retrieval forceps

BACKGROUND

Nickel hypersensitivity reactions can be an indication for the removal of intratubal microinserts used for hysteroscopic sterilization. Although early removal can be attempted hysteroscopically, hysteroscopic grasping forceps may be inadequate to grasp deeply positioned inserts.

CASE

Three days after hysteroscopic sterilization, the patient presented with a rash consistent with a nickel hypersensitivity reaction. Ten days after placement, we successfully performed hysteroscopic removal of an intratubal microinsert with tri-prong urologic stone retrieval forceps after standard hysteroscopic grasping forceps was unable to reach the deeply positioned device. Within 36 hours of bilateral microinsert removal, all symptoms resolved.

CONCLUSION

In difficult cases, 1-mm tri-prong urologic stone retrieval forceps can be useful for early hysteroscopic removal of intratubal microinserts.

[Interest of 3D ultrasound in the follow-up of tubal sterilizations: case report of a rare tubal perforation]

The Essure™ system's effectiveness is based on the follow-up at three months. The challenge is to find a minimally invasive imaging technique to locate the devices. Therefore, many authors recommend three-dimensional ultrasound in first-line. We report here an exceptional case of tubal perforation for which ultrasound failed to diagnose. Until then, only three cases have been reported in the literature, noting the difficulty to diagnose this complication. Indeed, although ultrasound is described as reliable, reproducible and non-radiating, it is a dynamic examination, operator dependent, exposing to the risk of misinterpretation.

Tubal risk markers for failure to place transcervical sterilization coils

BACKGROUND

There is a growing body of literature on placement rates of the Essure® procedure, yet prior studies have not attempted to identify tubal-associated risk factors for placement failures. The current study examines risk markers associated with the inability to deploy the Essure® coils into the tubal lumen using the new ESS305 design.

STUDY DESIGN

We used electronic medical record data to assess risk markers associated with the inability to place the Essure coils in the tubal lumen using the new ESS305 design. A total of 310 attempted procedures between June 14, 2007, and April 29, 2011, were analyzed.

RESULTS

There were 18 tubal failures (5.8%) out of the 310 attempted procedures. A history of a prior sexually transmitted infection (STI) was associated with tubal failure (odds ratio 2.64, 95% confidence interval 1.01-6.90, p=.048).

CONCLUSIONS

We speculate that the observed association between a prior STI and an inability to place the coil was due to a past history of pelvic inflammatory disease.

Hysterosalpingogram: an essential examination following Essure hysteroscopic sterilisation

OBJECTIVES

The aim of this study was to describe our experience of imaging following hysteroscopic sterilisation with the Essure (Conceptus Inc., Mountain View, San Carlos, CA) microinsert, and to underline the importance of a carefully performed follow-up hysterosalpingogram (HSG) in the management of these patients.

METHODS

18 women underwent the procedure and all returned for follow-up HSG. A standard HSG technique was used and views were acquired to establish microinsert position and tubal occlusion.

RESULTS

In 16 of the 18 women, adequate microinsert positioning and bilateral tubal occlusion was present. In one woman, a unilateral microinsert occluded the fallopian tube, whereas the other fallopian tube was ligated with a clip. The final patient underwent two studies; both showed well-positioned microinserts but unilateral free spill from the right fallopian tube. There are no reported pregnancies thus far.

CONCLUSION

Essure sterilisation coils have a unique appearance when radiographed and are an effective means of permanently occluding the fallopian tubes. HSG is a rapid and safe method of confirming satisfactory placement and tubal occlusion. Non-HSG imaging techniques are suboptimal at detecting patent fallopian tubes and expose patients to the risk of an unwanted and potentially complicated pregnancy.