Effectiveness and feasibility of hysteroscopic sterilization techniques: a systematic review and meta-analysis

Salpingectomy, tubal ligation and hysteroscopic occlusion for sterilization

INTRODUCTION

Sterilization of females is considered one of the most prevalent contraceptive techniques among women in the United States. There are many surgical sterilization procedures including salpingectomy, tubal ligation, and hysteroscopic occlusion of the fallopian tubes. We provide an overview of these methods from the clinical data and latest studies available on this topic.

EVIDENCE ACQUISITION

In order to review the latest literature on the topic, we searched electronic databases including PubMed, Web of Science, Scopus, and Cochrane library for all eligible studies from May 1st 2018 until May 1st 2022 using the following strategy: ("fallopian tube removal" OR Salpingectomy OR "fallopian tube excision" OR "tubal sterilization") AND ("tubal ligation" OR "bipolar coagulation" OR "tubal clip" OR "tubal ring" OR fimbriectomy). We reviewed every study that met our criteria and subjectively considered their results and methodology into this narrative review.

EVIDENCE SYNTHESIS

In addition to reviewing major guidelines in the United States, 19 recent studies met our eligibility criteria and were included in this review. We grouped the findings under the following headings: anatomical and physiological considerations, sterilization, salpingectomy, tubal ligation, and hysteroscopic tubal occlusion.

CONCLUSIONS

Bilateral salpingectomy and techniques of tubal ligation or occlusion continue to be effective procedures with good safety profiles. All techniques have similar surgical outcomes and long-term success rates. As salpingectomy has the advantage of reducing the risk of occurrence of ovarian cancer, this is preferential when feasible. Hysteroscopic occlusion techniques may be more minimally invasive but have the disadvantages of delayed efficacy, the need for a second invasive diagnostic procedure, and limited availability.

Nitinol Type Alloys General Characteristics and Applications in Endodontics

A very extensive literature review presents the possibilities and needs of using, in endodontics, the alloys commonly known as nitinol. Nitinol, as the most modern group of engineering materials used to develop root canals, is equilibrium nickel and titanium alloys in terms of the elements’ atomic concentration, or very similar. The main audience of this paper is engineers, tool designers and manufacturers, PhD students, and students of materials and manufacturing engineering but this article can also certainly be used by dentists. The paper aims to present a full material science characterization of the structure and properties of nitinol alloys and to discuss all structural phenomena that determine the performance properties of these alloys, including those applied to manufacture the endodontic tools. The paper presents the selection of these alloys’ chemical composition and processing conditions and their importance in the endodontic treatment of teeth. The results of laboratory studies on the analysis of changes during the sterilization of endodontic instruments made of nitinol alloys are also included. The summary of all the literature analyses is an SWOT analysis of strengths, weaknesses, opportunities, and threats, and is a forecast of the development strategy of this material in a specific application such as endodontics.

What Are the Chances of Resilon to Dominate the Market Filling Materials for Endodontics?

This paper is a literature review with additional virtual analyses of the authors’ own experimental research results. Knowledge from various areas was synergistically combined, appropriately for concurrent engineering, presenting several possible methodological approaches used in research, optimizing the selection of engineering materials and the conditions of their application with particular application in endodontics. Particular attention was paid to the theoretical aspects of filling material strengths, weaknesses, opportunities, and threats SWOT analysis. Attention was paid to the original concepts of Sustainable Dentistry Development in conjunction with Dentistry 4.0, which includes endodontics as an important element. The dentists’ actions, among others, in conservative dentistry, along with endodontics, requires close cooperation with engineers and the enginering sciences. Methods of root canal preparation were described, together with selected tools, including those made of nitinol. Principles concerning the process of cleaning and shaping the pulp complex are presented. The importance of obturation methods, including the Thermo-Hydraulic-Condensation THC technique, and the selection of filling materials with the necessary sealants for the success of endodontic treatment are discussed. The experimental studies were carried out in vitro on human teeth removed for medical reasons, except for caries, for which two groups of 16 teeth were separated. After the root canal was prepared, it was filled with studs and pellets of a filling material based on polyester materials, which has gained the common trade name of resilon or, less frequently, RealSeal (SybronEndo) with an epiphany sealant. The teeth for the first group were obturated by cold lateral condensation. In the second case the obturation was performed using the Thermo-Hydraulic-Condensation technique using System B and Obtura III. The experimental leakage testing was done using a scanning electron microscope SEM and a light stereoscopic microscope LSM, as typical research tools used in materialography. The research results, in a confrontation with the data taken from the literature studies, do not indicate the domination of resilon in endodontics.

Is Gutta-Percha Still the “Gold Standard” among Filling Materials in Endodontic Treatment?

The paper is an extensive monographic review of the literature, and also uses the results of the authors’ own experimental research illustrating the noticed developmental tendencies of the filling material based on gutta-percha. The whole body of literature proves the correctness of the research thesis that this material is the best currently that can be used in endodontics. Caries is one of the most common global infectious diseases. Since the dawn of humankind, the consequence of the disease has been the loss of dentition over time through dental extractions. Both tooth caries and tooth loss cause numerous complications and systemic diseases, which have a serious impact on insurance systems and on the well-being, quality, and length of human life. Endodontic treatment, which has been developing since 1836, is an alternative to tooth extraction. Based on an extensive literature review, the methodology of qualifying patients for endodontic treatment was analyzed. The importance of selecting filling material and techniques for the development and obturation of the root canal during endodontic treatment was described. Particular attention was paid to the materials science aspects and the sequence of phase transformations and precipitation processes, as well as the need to ensure the stoichiometric chemical composition of Ni–Ti alloys, and the vacuum metallurgical processes and material processing technologies for the effects of shape memory and superelasticity, which determine the suitability of tools made of this alloy for endodontic purposes. The phenomena accompanying the sterilization of such tools, limiting the relatively small number of times of their use, play an important role. The methods of root canal preparation and obturation methods through cold side condensation and thermoplastic methods, including the most modern of them, the thermo-hydraulic condensation (THC) technique, were analyzed. An important element of the research hypothesis was to prove the assumption that to optimize the technology of development and obturation of root canals, tests of filling effectiveness are identified by the density and size of the gaps between the root canal wall, and the filling methods used and devices appropriate for material research, using mainly microscopy such as light stereoscopic (LSM) and scanning electron (SEM). The most beneficial preparations were obtained by making a longitudinal breakthrough of 48 natural human teeth, extracted for medical reasons, different from caries, with compliance with all ethical principles in this field. The teeth were prepared using various methods and filled with multiple obturation techniques, using a virtual selection of experimental variants. The breakthroughs were made in liquid nitrogen after a one-sided incision with a narrow gap created by a diamond disc using a materialographic cutter. The best effectiveness of the root canal filling was ensured by the technology of preparing the root canals with K3 rotary nitinol tools and filling the teeth with the THC thermoplastic method using the System B and Obtura III devices with studs and pellets of filling material based on gutta-percha after covering the root canal walls with a thin layer of AH Plus sealant. In this way, the research thesis was confirmed.

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

A novel technology for reversible fallopian tubal occlusion using a reverse thermo-responsive polymer-Preliminary results from a rabbit animal study

OBJECTIVES

To determine if PF-88, a reverse thermo-responsive polymer designed to create a gel at body temperature and liquefy at a lower temperature (21°C) can reversibly occlude the fallopian tubes in rabbits.

STUDY DESIGN

Mature female New Zealand White rabbits underwent laparotomy and placement of 22-gage catheter into the lumen of the distil uterine horns for evaluation of tubal patency by fluoroscopy using radio opaque contrast and treatment with PF-88. In the Acute Phase group (n = 5) after PF-88 treatment we immediately cooled the serosal surface of the tube with ice for 90 seconds to liquify the gel then reassessed patency. In the Survival Phase groups, animals recovered from the initial surgery and then underwent a second procedure for evaluation of tubal occlusion and reversibility at 4 (n = 3), 14 (n = 2), and 28 (n = 3) weeks after the initial procedure. We compared the histologic appearance of the treated fallopian tubes to untreated controls (n = 3).

RESULTS

In the Acute Phase, we found all 10 fallopian tubes patent on initial evaluation, occluded following treatment with PF88, and patent following re-liquification by chilling. Animals in the Survival Group, all but one of the treated tubes appeared blocked at follow-up and patent following chilling. The treatment failure occurred in an animal in the 4-week group. Tubes treated with PF88 showed no histologic evidence of residual material or damage after removal of the polymer.

CONCLUSION

The PF-88 reverse thermo-responsive polymer demonstrated the ability to reversibly block fallopian tubes for up to 28 weeks.

IMPLICATIONS

The demonstration of reversible occlusion of the fallopian tube of rabbits using PF-88, a thermo-responsive reverse polymer, support additional studies to evaluate the potential of this polymer as a contraceptive in women.

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.

Safety and Assisted Reproductive Technology Outcomes of Hysteroscopic Tubal Microinserts Versus Laparoscopic Proximal Tubal Occlusion or Salpingectomy for Hydrosalpinges Treatment

OBJECTIVE

This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy?

METHODS

This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle.

RESULTS

Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure.

CONCLUSION

Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

Comparing options for women seeking permanent contraception in high-resource countries: a protocol for a systematic review

BACKGROUND

For women seeking permanent contraception, there are a variety of options available including surgical techniques such as tubal ligation or bilateral salpingectomy, in-clinic procedures such as hysteroscopic techniques using micro-inserts, or the levonorgestrel-releasing intrauterine contraceptive. Despite the various methods available for women who are seeking permanent contraception, there is not a review or decision-making tool that systematically brings together outcomes related to effectiveness, tolerability, adverse effects, non-contraceptive benefits, recovery, or accessibility: all of which are important for shared decision-making between patients and health care providers.

METHODS

We registered our protocol [on Prospero: CRD42016038254] following PRISMA guidelines. A search strategy was created in collaboration with a librarian, and three databases (EMBASE, PubMed, Web of Science) will be searched along with secondary screening of relevant articles. A third reviewer will adjudicate any discrepancies. Data will be extracted independently according to population, intervention, comparison, outcomes (PICOS); length of follow-up; and funding. Articles will be assessed for bias using the Newcastle-Ottawa Scale and the Cochrane Collaboration tool. If appropriate, a network meta-analysis will be conducted to rank and analyze each method according to each objective. If heterogeneity between studies is too high or it is not possible to conduct a network meta-analysis, a narrative analysis of the study results will be provided.

DISCUSSION

Clinicians and their patients seeking permanent contraception have several options, yet we were unable to find a systematic review or decision support tool helping to facilitate shared decision-making. This systematic review can inform patients, providers, and health policy decision-makers about which options of permanent contraception will meet different reproductive goals according to various outcomes, which can lead to better health, social, economic, and mental well-being for reproductive age women. This can also aid our understanding of resulting costs to the health care system.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016038254.

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.

Laparoscopic Sterilization Under Local Anesthesia with Conscious Sedation Versus General Anesthesia: Systematic Review of the Literature

Female sterilization is the most popular and common contraceptive method worldwide. Because hysteroscopic sterilization techniques are used less often due to side effects, the number of laparoscopic sterilization is increasing. A systematic overview concerning the most optimal anesthetic technique for laparoscopic sterilization is lacking. We performed a systematic review to compare conscious sedation with general anesthesia for laparoscopic sterilization procedures with respect to clinical relevant outcome measures, such as operating times, perioperative parameters and complications, patient comfort, recovery, and patient satisfaction. We searched Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized controlled trials comparing general anesthesia with conscious sedation for laparoscopic sterilization. Two authors (AGH and HAAMvV) abstracted and entered data into RevMan. Methodologic quality of the included trials was critically appraised. For our main outcome measures mean differences (continuous variables) and risk ratios (dichotomous variables) with 95% confidence intervals using random-effect models were calculated. Four randomized controlled trials were included comparing general anesthesia versus local anesthesia with conscious sedation for laparoscopic sterilization. The methodologic quality of the studies was moderate to good. Both techniques were comparable with regard to operating times, complications, and postoperative pain. However, local anesthesia with conscious sedation showed better results compared with general anesthesia with respect to recovery times, patient complaints of sore throat, and patient recovery and satisfaction. In conclusion, this systematic review about anesthetic techniques for laparoscopic sterilization showed that both general anesthesia and conscious sedation have no major anesthetic complications and may therefore be safe. Patients might benefit from conscious sedation in terms of recovery times, sore throat, and patient recovery and satisfaction, but only a few studies are included in the review and are relatively old. New research regarding this subject is needed to advise our patients most optimally in the future about the best anesthetic technique to be used when choosing for a laparoscopic sterilization procedure.

Essure® present controversies and 5 years' learned lessons: a retrospective study with short- and long-term follow-up

BACKGROUND

The risk-benefit of contraception with Essure® is being readdressed due to an increase of reports of adverse effects with this device. Our aim was to proceed to an internal quality evaluation and to identify opportunities for protocol improvement. We proceeded to a one-center, retrospective consecutive case series of women admitted for Essure® placement, from 1 January 2012 until 31 December 2016 (5 years).

RESULTS

In a total of 274 women, technical difficulties were mainly unilateral, with no acute or short-term severe complications. The procedure was brief (median 3.2 min, IQR 2.5-5.2) and moderately painful (median of 4 in a 0-10 scale; IQR 3-5). At 3 months, the failure rate was 2%, with no pregnancies. Second surgery indication (< 1%) resumed to a case of nickel hypersensitivity. At 1 year, pregnancy rate was 1%. Ninety-eight percent of the patients would recommend the method.

CONCLUSIONS

We identified high patient satisfaction and low failure rates, both at short and long term. Investigation about whether some women still have patent tubes at the 3-month follow-up could lead to protocol improvement. It is important that clinicians look for second causes for adverse effects related to Essure® and avoid the erroneous indication for implant removal. Long follow-up allowed for both internal quality evaluation and clarification of misconception; it could possibly also have contributed to patient satisfaction.

Reproducibility of the interpretation of coronal 3D ultrasound view of the uterus to evaluate the position of Essure® 3 months after hysteroscopic procedure

OBJECTIVE

Three-dimensional sonography is a good alternative method to assess the position of microinserts. Adequate position after three months allows for the interruption of other contraception. Objective is to evaluate inter-observer reproducibility of the interpretation of coronal transvaginal 3D ultrasound view of the uterus to evaluate the position of Essure®.

STUDY DESIGN

Inter-observer reproducibility study. Fifty women underwent successful bilateral placement of microinserts (Essure®) by hysteroscopy in the Department of Gynaecology of a teaching hospital and were included in the study. At three month, 3D ultrasound coronal views of the fifty uterus (accounting for one hundred microinserts) were assessed by five different observers and microinsert position was classified according to the classification described by Legendre et al. Inter-observer reproducibility in reading the 3D coronal view of the uterus was evaluated.

RESULTS

The k-value was disparate, from 0.26 to 0.82. Inter-observer reproducibility then ranged from fair to almost perfect, depending on a prior knowledge of the position classification.

CONCLUSIONS

Transvaginal 3D coronal view of the uterus is sufficient to assess the positioning of the microinserts when the practionner or the surgeon is familiar with the classification method.

Tubal patency during the menstrual cycle and during treatment with hormonal contraceptives: a pilot study in women

Background

Hysterosalpingram (HSG) evaluation of tubal patency is typically performed in the follicular phase, but data to support this timing are lacking.

Purpose

To determine whether menstrual cycle phase or hormonal treatments affect observation of tubal patency during HSG.

Material and Methods

Ten participants underwent repeated HSG examinations: during the follicular and luteal phase of a natural menstrual cycle; 30 days following continuous administration of a combined oral contraceptive (COC); and 30 days after an intramuscular injection of depo medroxyprogesterone (DMPA) acetate. Participants with tubal blockade following DMPA had a fifth HSG 30 days following a second course of COCs. The primary outcome was tubal patency.

Results

All 10 participants demonstrated bilateral tubal patency (BTP) on at least one HSG examination during the study. One participant showed bilateral functional occlusion (FO) during the follicular phase examination, but BTP with the luteal phase, COC cycle, and DMPA exams. One participant with BTP discontinued participation and nine completed the COC HSG exam with BTP in seven, and one each with bilateral or unilateral FO. Seven participants completed the DMPA HSG with BTP in six and unilateral FO in one; BTP was seen in the final HSG after restarting the COC.

Conclusion

This pilot study supports the luteal phase of natural cycles as the optimum time for evaluation of tubal patency. The occurrence of functional occlusion of the fallopian tube on HSG examination performed during the follicular phase and following contraceptive steroid treatment supports a role of hormonal action on the utero-tubal junction.

Algorithm of Transvaginal Ultrasound and/or Hysterosalpingogram for Confirmation Testing at 3 Months after Essure Placement

STUDY OBJECTIVE

To evaluate the algorithm of transvaginal ultrasound (TVU) and/or modified hysterosalpingogram (HSG) confirmation testing 3 months after Essure placement to determine if women can rely on the device for permanent birth control.

DESIGN

Interim analysis of an ongoing 10-year, prospective, multicenter, nonrandomized, single-arm, international trial (Canadian Task Force classification II-2).

SETTING

Twenty study centers in the United States (n = 12), Canada (n = 1), The Netherlands (n = 6), and Spain (n = 1).

PATIENTS

Women undergoing the Essure procedure for permanent birth control.

INTERVENTIONS

Based on the algorithm for confirmation testing, women with an uncomplicated Essure procedure underwent TVU as the confirmation test; modified HSG was used for women ineligible for TVU, when TVU findings were abnormal or inconclusive, or based on the physician's discretion.

MEASUREMENTS AND MAIN RESULTS

Co-primary endpoints (intention-to-treat [ITT] population) were the reliance rate and the 1-year pregnancy rate. Safety evaluation was based on adverse events. Bilateral insert placement was attempted in 597 women (ITT population) and achieved in 582 of 597 (97.5%). A total of 547 women were told to rely on Essure for permanent birth control. Both co-primary endpoints met prespecified limits: based on Bayesian statistics, the reliance rate was 91.6% (547/597; 95% credible interval, 89.2%-93.6%) and the 1-year pregnancy rate .67% (95% credible interval, .16%-1.53%). Using the algorithm for confirmation testing, of 547 subjects told to rely on Essure, 470 (86%) underwent TVU alone, 30 (6%) had modified HSG alone, and 47 (9%) had TVU followed by modified HSG. Four women became pregnant after being told to rely on Essure. They all had confirmation testing with TVU alone, and each initially read incorrectly as optimal insert locations. In each case postpregnancy follow-up and root cause analysis revealed unsatisfactory insert locations, 2 of which were perforations. Most adverse events were mild and unrelated to Essure.

CONCLUSION

The algorithm of TVU and/or modified HSG confirmation testing 3 months after Essure placement can determine that a woman can rely on the device for permanent birth control. The adverse events observed are consistent with the known safety profile of Essure. (clinicaltrials.gov: NCT01327105.).

Definitive Contraception: Trends in a Ten-year Interval

Objective To evaluate the trends in definitive contraception in a ten-year interval comprising the years 2002 and 2012. Method Retrospective analysis of the tubal sterilization performed in our service in 2002 and 2012, analyzing the demographic characteristics, personal history, previous contraceptive method, definite contraception technique, effectiveness and complications. Results Definitive contraception was performed in 112 women in 2002 (group 1) and in 60 women in 2012 (group 2). The groups were homogeneous regarding age, parity, educational level and personal history. The number of women older than 40 years choosing a definitive method was more frequent in group 1, 49.1% (n = 55); for group 2, the rate was 34.8% (n = 23) (p = 0.04). The time between the last delivery and the procedure was 11.6 ± 6.2 and 7.9 ± 6.4 years (p = 0.014) in 2002 against 2012 respectively. In 2002, all patients performed tubal ligation by laparoscopic inpatient regime. In 2012, the bilateral placement of the Essure (Bayer Corporation, Whippany, NJ, US) device was suggested to 56.1% (n = 37) of the patients, while laparoscopy was suggested to 43.9% (n = 29) of them. All women who underwent laparoscopic sterilization had the procedure successfully completed using silastic rings. The overall bilateral device placement rate for the Essure was 91.6%, with only one complication reported. All Essure procedures were performed in an outpatient setting; for the laparoscopy, this rate was 79% (n = 15). No intentional pregnancies occurred until this date. Conclusions There is a trend in the decrease in definitive contraception over the years in our institution, maybe as a result of the development of long-acting reversible contraceptives. The hysteroscopic procedure has become a frequent option, as it is performed in an office setting without anesthesia, being a well-tolerated, minimal invasive method.

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.

Analysis of surgeries performed after hysteroscopic sterilization as tabulated from 3,803 Essure patient experiences

Objective

Although previous research has suggested that risk for reoperation among hysteroscopic sterilization (HS) patients is more than ten times higher than for patients undergoing standard laparoscopic tubal ligation, little has been reported about these subsequent procedures.

Methods

This descriptive cohort study used a confidential online questionnaire to gather data from women (n=3,803) who volunteered information on HS followed by device removal surgery performed due to new symptoms developing after Essure placement.

Results

In this sample, mean age was 35.6 years and women undergoing hysterectomy after HS comprised 64.9% (n=2,468). Median interval between HS and hysterectomy was 3.7 (interquartile range, 3.9) years and mean age at hysterectomy was 36.3 years. Some patients (n=1,035) sought removal of HS devices and fallopian tubes only, while other miscellaneous gynecological procedures were also occasionally performed for Essure-associated symptoms. When data from all patients who had any post-Essure surgery besides hysterectomy were aggregated (e.g., device removal + “other” cases, n=1,335) and compared to those cases undergoing hysterectomy, mean age was significantly lower than for the hysterectomy group (34.4 vs. 36.3 years, respectively; P<0.01); uterus-conserving surgeries were also typically performed significantly earlier than hysterectomy (P<0.01).

Conclusion

This investigation is the first to characterize specific gynecological operations after Essure, and suggests that the predominant surgical answer to HS complaints is hysterectomy for many women. Dissatisfaction with HS may represent an important indication for hysterectomy and additional study is needed to quantify this phenomenon.

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.

Preliminary Assessment of a Hysteroscopic Fallopian Tube Heat and Biomaterial Technology for Permanent Female Sterilization

Recent failures in hysteroscopic female sterilization procedures have brought into question the implantation of non-resorbable metal devices into the fallopian tubes due to long-term risks such as migration, fragmentation, and tubal perforation. The goal of this study is to assess whether a porous, biodegradable implant can be deposited into the fallopian tube lumen with or without a local mild heat treatment to generate a safe and permanent fallopian tube occlusion/sterilization event. The technologies investigated included freeze-cast collagen-based scaffolds and magnetic nanoparticle (MNP) based scaffolds. In vitro assessment of iron oxide MNP-based scaffolds was performed to determine the absorption rate density (ARD); subsequent computational modeling quantified the thermal in vivo steady state temperature as a function of tubal radius for treatment planning. For collagen-based scaffolds, in vivo testing was performed to study the biocompatibility in a mouse flank model, followed by implantation into an in vivo anestrus feline uterine horn (animal model for the fallopian tube). Biological responses were studied histopathologically. Uterine horn patency was assessed via radiographic imaging. Preliminary studies suggest the MNP-impregnated scaffold and a safe, noninvasive AMF excitation field have potential to generate a sufficient focal fallopian tube thermal dose to create a fibrotic healing event and ultimately, permanent tubal occlusion.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3627 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures appear to be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Combined hysteroscopy-laparoscopy approach for excision of pelvic nitinol fragment from Essure contraceptive device: Role of intraoperative fluoroscopy for uterine conservation

We describe the successful removal of a pelvic contraceptive coil in a symptomatic 46-year-old patient who had Essure devices for four years, using a combined hysteroscopy-laparoscopy-fluoroscopy approach. Following normal hysteroscopy, at laparoscopy the right Essure implant was disrupted and its outer nitinol coil had perforated the fallopian tube. However, the inner rod (containing polyethylene terephthalate) had migrated to an extrapelvic location, near the proximal colon. In contrast, the left implant was situated within the corresponding tube. Intraoperative fluoroscopy was used to confirm complete removal of the device, which was further verified by postoperative computed tomography. The patient's condition improved after surgery and she continues to do well. This is the first report to describe this technique in managing Essure complications remote from time of insertion. Our case highlights the value and limitations of preoperative and intraoperative imaging to map Essure fragment location before surgery.

Initial experience with hysteroscopic tubal occlusion (Essure®)

Objective

To evaluate results of early tubal occlusions performed by hysteroscopy (Essure^®)_.

Methods

This prospective study included 38 patients, 73.7% of them were white, mean age 34.5 years, they have had on average 3 pregnancies and 2.7 of deliveries. A total of 86.8% of patients previously prepared the endometrium. All procedures were carried out at outpatient unit without anesthesia.

Results

Insertion rate of the device was 100% at a mean time of 4 minutes and 50 seconds. Based on the analogical visual scale, average pain reported was three, and 55.3% of women did not report pain after the procedure. After 3 months, 89.5% of patients were very satisfied with the method. Simple radiographs of the pelvis showed 92.1% of topical devices, and one case of unilateral expulsion had occurred. A four years follow-up did not show failure in the method.

Conclusions

Tubal occlusion through hysteroscopy at outpatient unit and without anesthesia was a quickly and well-tolerated procedure. No serious complications were seen, the success rate was high, and patients were satisfied.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3827 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was statistically significantly higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures may be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.