Incorrect position of Essure microinserts 3 months after successful bilateral placement

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.

Use of Hysterosalpingo-Foam Sonography for Assessment of the Efficacy of Essure Hysteroscopic Sterilization

OBJECTIVES

Hysterosalpingo-foam sonography (HyFoSy) has been suggested to be a possible less invasive alternative to hysterosalpingography (HSG), which is the reference standard for confirmation of tubal occlusion after Essure (Bayer AG, Leverkusen, Germany) hysteroscopic sterilization. The purpose of our study was to evaluate the accuracy of HyFoSy compared to HSG for confirmation of tubal occlusion after Essure hysteroscopic sterilization.

METHODS

A prospective study included 90 patients who underwent Essure hysteroscopic sterilization. Twelve weeks after the sterilization, 2-dimensional transvaginal ultrasonography was performed to assess the microinsert position and was followed by HyFoSy and HSG for evaluation of tubal occlusion. Patients with patent fallopian tubes on HSG were scheduled for additional HSG procedures at 3-month intervals until tubal occlusion was documented.

RESULTS

Of 90 enrolled patients, 86 patients with 170 fallopian tubes underwent the complete imaging protocol. Tubal occlusion was evaluated by HyFoSy as an index test and HSG as a reference standard. The accuracy of HyFoSy was 97.1% (95% confidence interval [CI], 93%-99%). The sensitivity and specificity were 100% (95% CI, 97%-100%) and 54.6% (95% CI, 23%-83%), whereas the positive and negative predictive values were 97.0% (95% CI, 93%-99%) and 100% (95% CI, 42%-100%), respectively. No long-term complications were reported for HyFoSy or HSG.

CONCLUSIONS

Given that the concordance rate for tubal occlusion between HyFoSy and HSG was not 100%, an occluded fallopian tube on HyFoSy should be confirmed by HSG, which remains the reference standard for confirmation of tubal occlusion after Essure hysteroscopic sterilization.

Design, Manufacture, and In vivo Testing of a Tissue Scaffold for Permanent Female Sterilization by Tubal Occlusion

Current FDA-approved permanent female sterilization procedures are invasive and/or require the implantation of non-biodegradable materials. These techniques pose risks and complications, such as device migration, fracture, and tubal perforation. We propose a safe, non-invasive biodegradable tissue scaffold to effectively occlude the Fallopian tubes within 30 days of implantation. Specifically, the Fallopian tubes are mechanically de-epithelialized, and a tissue scaffold is placed into each tube. It is anticipated that this procedure can be performed in less than 30 minutes by an experienced obstetrics and gynaecology practitioner. Advantages of this method include the use of a fully bio-resorbable polymer, low costs, lower risks, and the lack of general anaesthesia. The scaffold devices are freeze-cast allowing for the custom-design of structural, mechanical, and chemical cues through material composition, processing parameters, and functionalization. The performance of the biomaterial and de-epithelialization procedure was tested in an in vivo rat uterine horn model. The scaffold response and tissue-biomaterial interactions were characterized microscopically post-implantation. Overall, the study resulted in the successful fabrication of resilient, easy-to-handle devices with an anisotropic scaffold architecture that encouraged rapid bio-integration through notable angiogenesis, cell infiltration, and native collagen deposition. Successful tubal occlusion was demonstrated at 30 days, revealing the great promise of a sterilization biomaterial.

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.

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.

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).

Improving adherence to hysterosalpingography after hysteroscopic sterilization using an electronic reminder

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.

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.

Hysteroscopic sterilization in the office setting

Hysteroscopic sterilization is growing in popularity. Nearly 500,000 women have been sterilized using this method, and an increasing number of physicians are now performing this procedure in the office setting. The office setting can provide a cost-effective, convenient, and safe environment for hysteroscopic sterilization. Patients may benefit from avoiding hospital preoperative visits, excessive laboratory evaluation, operating room wait times, and expense associated with hospital care. Physicians may improve productivity through remaining in their office or avoiding operating room delays. This article reviews office-hysteroscopic sterilization with the Essure microinsert system.

Radiographic morphology of fallopian tubes in women of child-bearing potential: a descriptive study

AIM

The aim of this study was to determine the radiographic morphological characteristics of fallopian tubes in women of child-bearing age.

MATERIAL AND METHODS

From 2007 to 2008 we retrospectively collected records from women aged 19-45 years undergoing fertility evaluation who had normal salpingograms. Women were excluded if they had abnormal imaging on salpingogram, ultrasound, or hysteroscopy, and if they had any history of pelvic disease or pathology, were febrile, or were taking oral contraceptives at the time of the salpingogram.

RESULTS

We analyzed the salpingograms from 100 women. The interstitial portion of the tube is funnel-shaped. The mean diameter of the proximal tubal opening was 1.07 ± 0.43 mm. The mean length of the interstitial portion was 5.27 ± 4.28 mm, and the mean internal diameters of the middle and distal segments of the interstitial portion were 0.50 ± 0.22 mm and 0.32 ± 0.12 mm, respectively. The narrowest part of the fallopian tube was the distal segment of the interstitial portion, which is significantly different from the internal diameter of the isthmus (0.46 ± 0.28 mm) (P < 0.01).

CONCLUSIONS

This study provides detailed data of the normal fallopian tube that may be of value in the development of new contraceptive agents, as well as infertility treatments.

Necessity of hysterosalpingography after Essure microinsert placement for contraception

OBJECTIVE

The objective of our study was to determine whether hysterosalpingography is necessary after Essure microinsert placement by evaluating the rates of appropriate placement and of satisfactory tubal occlusion in a general population.

MATERIALS AND METHODS

We identified all patients who underwent hysterosalpingography after Essure microinsert placement for desired sterility between January 1, 2008, and August 1, 2010. We recorded demographic information and the hysterosalpingographic results. The images and operative reports of all cases with abnormal hysterosalpingographic findings were reviewed. The hysterosalpingographic results were reviewed for appropriate placement of the microinsert, for successful tubal occlusion, and for any additional abnormalities. We also reviewed the medical records for documentation of subsequent pregnancies.

RESULTS

Two hundred forty hysterosalpingographic examinations were performed after 237 hysteroscopic microinsert placement procedures in 235 women. The mean age of the subjects was 35 years (range, 20-50 years). Twenty-two examinations (9.2%) were abnormal. Fourteen (5.8%) revealed inappropriate placement: six with tubal occlusion, seven without tubal occlusion, and one with an indeterminate finding for tubal occlusion. Fifteen examinations (6.3%) showed tubal nonocclusion: Microinsert placement was inappropriate in seven cases and appropriate in eight. Of the 22 abnormal hysterosalpingographic examinations, 20 had operative reports available. Eleven (55%) described difficulties with device insertion. Forty-two endometrial abnormalities were described in hysterosalpingographic reports of 38 patients. One subsequent pregnancy was documented in a patient with satisfactory device placement and tubal occlusion on hysterosalpingography.

CONCLUSION

Hysterosalpingography after Essure microinsert placement is necessary because 6.3% of examinations showed abnormalities requiring an alternative form of contraception.

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.