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Zou C, Davis B, Wigle PR, Hincapie AL, Guo JJ. Safety reporting of Essure medical device: a qualitative and quantitative assessment on the FDA manufacturer and user facility device experience database in 2018. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1172927. [PMID: 37519343 PMCID: PMC10374426 DOI: 10.3389/frph.2023.1172927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Background There have been numerous cases of adverse events since the introduction of Essure medical devices for sterilization in 2002. This study analyzed the safety event reports of the Essure reported in the Manufacturer and User Facility Device Experience (MAUDE). Methods A retrospective analysis examined the MAUDE reports between Jan-1, 2018, and Oct-31, 2018 and focused on safety reports related to the Essure device. Safety reports were categorized and analyzed by their event type, device problem, patients' symptoms and the level of harm. Of this study cohort, 10% of samples were randomly selected for quantitative analyses. Thematic analysis was conducted for reports included death cases. Results A total of 4,994 eligible reports were analyzed. There were ten reports associated with individuals' deaths, and the main themes of safety reports from qualitative analysis were pains, bleeding, surgery, migraine, and infection. Quantitative analysis of 500 randomly selected samples showed that 98% of adverse event reports were associated with different injuries such as surgery, pain, bleeding, hysterectomy, and menorrhagia. Additionally, more than 90% of reports were submitted by the manufacturer. Conclusion These findings indicated several safety issues of Essure. More meaningful pre- and post-marketing surveillance and regulation are warranted in the medical device market to ensure safety and effectiveness, including investigating complaints, promptly sharing relevant information with regulators and users, and implementing corrective actions.
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Affiliation(s)
- Chenyu Zou
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, United States
| | - Brandy Davis
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, United States
| | - Patricia R. Wigle
- Division of Pharmacy Practice & Administrative Sciences, The James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
| | - Ana L. Hincapie
- Division of Pharmacy Practice & Administrative Sciences, The James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
| | - Jeff Jianfei Guo
- Division of Pharmacy Practice & Administrative Sciences, The James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
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Patil E, Thurmond A, Hart K, Seguin J, Edelman A, Jensen JT. Intrauterine fluid instillation to confirm tubal occlusion after transcervical permanent contraception: A pilot study .. Contraception 2019; 101:40-45. [PMID: 31655066 DOI: 10.1016/j.contraception.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine if women with tubal patency experience more fluid loss compared to those with bilateral tubal occlusion following intrauterine instillation of fluid via a balloon catheter. STUDY DESIGN In this prospective cohort pilot study, we enrolled women with prior Essure® procedures and healthy controls from September 2016 to July 2017. We excluded women using an implant or intrauterine device, or with a prior cesarean delivery or permanent contraception procedures other than Essure®. An infusion pump delivered saline via balloon catheter under continuous pressure monitoring. After one minute, we withdrew the fluid and recorded volumes in and out. Subjects then underwent hysterosalpingogram for evaluation of tubal patency. We conducted crude analyses with t-tests and sensitivity analyses. RESULTS We recruited 23 participants; ten provided analyzable data in each group. Hysterosalpingogram confirmed patency in all control and occlusion in all post-Essure® subjects in the analysis group. We found the median volume of saline lost among control subjects [7.8 mL (7.4, 8.4)] larger than post-Essure® participants [2.2 mL (2.0, 3.8), p < 0.01]. While 50% of control subjects tolerated the full 10 mL of fluid instillation, none of the post-Essure® subjects tolerated this volume (p = 0.03). A combination of saline loss ≤4 mL and participant intolerance of the full 10 mL volume yielded sensitivity of 0.80 (95% CI: 0.57, 1.00) and specificity of 1.00 for bilateral tubal occlusion. CONCLUSION Instillation of a fixed volume into the uterus may discriminate between women with tubal patency and occlusion following permanent contraception procedures with high specificity and adequate sensitivity. These findings should be validated in larger, more diverse study populations. IMPLICATIONS Confirmation of tubal occlusion following permanent contraception with an office-based approach could improve acceptability of transcervical approaches. The recent removal of Essure® from the U.S. market increases the need for novel transcervical procedures and occlusion verification methods.
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Affiliation(s)
- Eva Patil
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN 50, Portland, OR 97239, USA.
| | - Amy Thurmond
- Womens Imaging & Intervention, 17050 Pilkington Rd, Suite 130, Lake Oswego, OR 97035, USA
| | - Kyle Hart
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN 50, Portland, OR 97239, USA
| | - Jacqueline Seguin
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN 50, Portland, OR 97239, USA
| | - Alison Edelman
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN 50, Portland, OR 97239, USA
| | - Jeffrey T Jensen
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN 50, Portland, OR 97239, USA
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Patil E, Thurmond A, Edelman A, Fu R, Lambert W, Seguin J, Jensen JT. Pressure dynamics in the non-gravid uterus: intrauterine pressure cannot confirm tubal occlusion after non-surgical permanent contraception. Contraception 2017; 96:330-335. [PMID: 28687179 DOI: 10.1016/j.contraception.2017.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/13/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective was to determine if intrauterine pressure can distinguish bilateral tubal occlusion (BTO) from unilateral or bilateral tubal patency (TP) in women following a permanent contraception procedure. STUDY DESIGN We used a small inline pressure sensor to continuously monitor intrauterine pressure during hysterosalpingogram (HSG) in a cross-sectional study that enrolled women having HSGs for any indication. The primary outcome was the peak intrauterine pressure compared between women with BTO and TP as verified by HSG. RESULTS We enrolled 150 subjects, of which 111 (74.0%) provided usable pressure readings. Of these, 98/111 (88.3%) had TP, and 13 (11.7%) had BTO. There was no difference in peak intrauterine pressure for subjects with TP (mean 293.8±58.7 mmHg) compared to those with BTO (292.7±71.3 mmHg, p=.95). Among parous women, peak intrauterine pressure in subjects with BTO (311.9±78.0 mmHg) was higher but not significantly different from subjects with TP (282.7±49.2 mmHg, p=.20). In linear regression analysis, peak intrauterine pressure was not associated with age, body mass index, gravidity or having at least one prior live birth. CONCLUSIONS Measurement of peak intrauterine pressure does not distinguish between women with patent and blocked fallopian tubes. This approach would not be clinically useful to verify occlusion following permanent contraception. IMPLICATIONS Peak intrauterine pressure does not differ between women with patent and occluded fallopian tubes and cannot be used to confirm tubal occlusion after nonsurgical permanent contraception.
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Affiliation(s)
- Eva Patil
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Amy Thurmond
- Womens Imaging & Intervention, 17050 Pilkington Rd, Suite 130, Lake Oswego, OR 97035, USA
| | - Alison Edelman
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Rongwei Fu
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - William Lambert
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jacqueline Seguin
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jeffrey T Jensen
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
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Wahl H, Bell J, Skinner B. Laparoscopic Removal of a Retroperitoneal Hysteroscopic Microinsert Using Fluoroscopy. J Minim Invasive Gynecol 2017; 24:174-176. [PMID: 27687852 DOI: 10.1016/j.jmig.2016.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/15/2016] [Accepted: 09/18/2016] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Heather Wahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
| | - Jason Bell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; Program on Women's Health Care Effectiveness Research, University of Michigan, Ann Arbor, Michigan
| | - Bethany Skinner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; Division of Minimally Invasive Surgery, University of Michigan, Ann Arbor, Michigan
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Basinski CM, Juran RS, Fein A. Essure© Sterilization: Experience and Outcomes with 1024 Patients in a Solo Practice Over 8 Years. J Gynecol Surg 2016. [DOI: 10.1089/gyn.2015.0103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Carney PI, Lin J, Xia F, Law A. Temporal trend in the use of hysteroscopic vs laparoscopic sterilization and the characteristics of commercially insured and Medicaid-insured females in the US who have had the procedures. Int J Womens Health 2016; 8:137-44. [PMID: 27257393 PMCID: PMC4872274 DOI: 10.2147/ijwh.s105906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Limited research has examined the factors associated with female permanent contraception procedures. This study evaluated the temporal trend in the use of hysteroscopic sterilization (HS) vs laparoscopic sterilization (LS) and characteristics of commercially insured and Medicaid-insured women in the US who have had the procedures. METHODS Women aged 15-49 years with claims for HS and LS procedures were identified from two MarketScan databases, one consisting of commercial claims and the other Medicaid claims, during the time period of January 1, 2003 to December 31, 2012 and January 1, 2006 to December 31, 2011, respectively. Proportions and characteristics of women who underwent HS or LS procedures were determined. Multivariable logistic regressions were used to identify characteristics associated with the use of HS vs LS. RESULTS Commercially insured women who had HS (n=32,012) vs LS (n=64,725) were slightly older (37.2 years vs 36.4 years, respectively, P<0.001) but had similar Charlson Comorbidity Index scores. Among commercially insured women, those who had a sterilization procedure during 2008-2012 were more likely to undergo HS (odds ratio: 7.1, P<0.001) than those who had a sterilization procedure during 2003-2007. Medicaid-insured women who had HS (n=2,001) were also slightly older than women who had LS (n=12,523; 30.1 years vs 28.8 years, respectively, P<0.001) but had a higher mean Charlson Comorbidity Index score (0.32 vs 0.25, respectively, P<0.001). Among Medicaid-insured women, the likelihood of having HS vs LS increased 3.3-fold (P<0.001) in years 2009-2011 compared to years 2006-2008. Among both populations, older age, obesity, and the use of oral contraceptives within the previous 12 months were associated with having HS vs LS. CONCLUSION Among both commercially insured and Medicaid-insured women, the likelihood of having HS vs LS increased over time.
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Affiliation(s)
- Patricia I Carney
- Medical Affairs, Bayer HealthCare Pharmaceuticals, Inc, Whippany, NJ, USA
| | - Jay Lin
- Novosys Health, Green Brook, Whippany, NJ, USA
| | - Fang Xia
- Health Economics and Outcomes Research, Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ, USA
| | - Amy Law
- Health Economics and Outcomes Research, Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ, USA
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Hoyos LR, Leon-Peters J, Berman JM, Hertz M. Pregnancy following hysteroscopic sterilization at an Urban Abortion Clinic- A case series: Are We looking in the wrong places? Contraception 2016; 94:78-80. [PMID: 27000998 DOI: 10.1016/j.contraception.2016.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/22/2016] [Accepted: 02/28/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Hysteroscopic sterilization (HS) has become one of the most common permanent contraception methods in the U.S. However, recent evidence suggests that the failure rate may be higher than previously reported. We describe women with a history of HS presenting for abortion at a 3-site urban abortion clinic. STUDY DESIGN Retrospective case series of patients with previous HS who presented to a 3-site urban abortion clinic for pregnancy termination from October 2012 to February 2015. RESULTS In 28months, 9 patients with prior HS had failure of the method and then an abortion. CONCLUSIONS This study identifies a number of failures from a setting previously unaccounted. It suggests that perhaps the failure rate is higher than previously reported. The cases here presented, from a 3-site urban abortion clinic over 28months, almost match and sometimes surpass the number of failures reported in multicenter case series in the literature. Surveys of other abortion clinics in the U.S. and elsewhere might also discover other patients whose HS had failed. IMPLICATIONS We identified a number of hysteroscopic sterilization failures at termination of pregnancy at a 3-site urban abortion clinic. We hypothesize that the HS failure rate underestimates the true method failure because previous analysis have excluded cases such as these.
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Affiliation(s)
- Luis R Hoyos
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women's Hospital, 3990 John R, 7-Brush N, Mail Box 165, Detroit, MI, 48201, USA.
| | - Jocelyn Leon-Peters
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women's Hospital, 3990 John R, 7-Brush N, Mail Box 165, Detroit, MI, 48201, USA.
| | - Jay M Berman
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women's Hospital, 3990 John R, 7-Brush N, Mail Box 165, Detroit, MI, 48201, USA.
| | - Michael Hertz
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women's Hospital, 3990 John R, 7-Brush N, Mail Box 165, Detroit, MI, 48201, USA.
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Abstract
PURPOSE OF REVIEW Permanent methods are the most commonly used contraceptive options worldwide. Even with the increase in popularity and accessibility of long-acting reversible methods, there remains high demand for permanent options, especially among women in developing countries. RECENT FINDINGS Traditional methods of permanent contraception, such as postpartum tubal ligation and interval surgical tubal occlusion or electrocautery by mini-laparotomy or laparoscopy are well tolerated and highly effective. Bilateral total salpingectomy for ovarian cancer risk reduction is currently being investigated. Hysteroscopic tubal occlusion reduces or eliminates the need for anesthesia, but requires surgical training and specialized equipment. Alternative permanent contraception methods are being explored including immediately effective hysteroscopic methods, and nonsurgical permanent contraception methods that have the potential to improve access and reduce cost. SUMMARY Permanent contraception methods are an important part of the contraceptive methods mix designed to meet the needs of women who have completed desired family size or wish never to become pregnant. Current surgical approaches to permanent contraception are well tolerated and highly effective. The development of a highly effective nonsurgical approach could simplify the provision of permanent contraception.
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Affiliation(s)
- Eva Patil
- Oregon Health & Science University, Department of Obstetrics and Gynecology, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, (503) 418 4500
| | - Jeffrey T. Jensen
- Oregon Health & Science University, Department of Obstetrics and Gynecology, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, (503) 418 4500
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Chudnoff SG, Nichols JE, Levie M. Hysteroscopic Essure Inserts for Permanent Contraception: Extended Follow-Up Results of a Phase III Multicenter International Study. J Minim Invasive Gynecol 2015; 22:951-60. [DOI: 10.1016/j.jmig.2015.04.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/16/2015] [Accepted: 04/19/2015] [Indexed: 10/23/2022]
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Moureau D, Laurent N, Rubod C, Lucot JP, Salleron J, Faye N. Evaluation of tubal microinserts position using 3D ultrasound and pelvic X-ray. Diagn Interv Imaging 2015; 96:1133-40. [PMID: 26163222 DOI: 10.1016/j.diii.2014.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 04/30/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE To retrospectively compare three-dimensional ultrasonography (3D-US) and pelvic X-rays to assess the position of tubal sterilization microinserts. MATERIAL AND METHODS Forty-four patients who underwent tubal sterilization with Essure(®) microinserts in our institution were included. The microinserts'position was evaluated three months after the procedure using 3D-US and pelvic X-rays. Placement on 3D-US was binary categorized as correct or incorrect and the distance between the two devices was reported. The orientation and symmetric deployment of the microinserts and the distance between the proximal parts of the two devices was assessed on pelvic X-rays. Performance of 3D-US and pelvic X-ray were compared using Mac Nemar test. Comparison of the distance between the two devices measured on pelvic X-rays and 3D-US was made with the paired Student t test. RESULTS 3D-US images showed microinserts in 93% (41/44). Eighty-six percent (38/44) were correctly positioned on 3D-US and 82% (36/44) on pelvic X-rays. No significant differences between the performances of the two imaging techniques were found. No significant differences for the distance between the two devices measured on pelvic X-ray and 3D-US was found. CONCLUSION 3D-US is a simple, non-ionizing technique, which appears as a promising alternate technique to pelvic X-rays to assess the correct position of Essure(®) microinserts.
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Affiliation(s)
- D Moureau
- Women Medical Imaging Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France.
| | - N Laurent
- Women Medical Imaging Department, Valenciennes Hospital, Lille Nord University, Valenciennes, France
| | - C Rubod
- Gynecology Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France
| | - J P Lucot
- Gynecology Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France
| | - J Salleron
- Department of Biostatistics, EA2694, UDSL, Lille University, Lille, France
| | - N Faye
- Women Medical Imaging Department, Jeanne-de-Flandre Hospital, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille, France
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Gariepy AM, Creinin MD, Smith KJ, Xu X. Probability of pregnancy after sterilization: a comparison of hysteroscopic versus laparoscopic sterilization. Contraception 2015; 91:521. [PMID: 25769439 DOI: 10.1016/j.contraception.2015.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Aileen M Gariepy
- School of Medicine, Department of Obstetrics, Gynecology, Reproductive Sciences, 333 Cedar Street, PO Box 208063, New Haven, CT 06520-8063, USA.
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The history and current status of fallopian tube pressures - developing alternate methods for confirmation of tubal occlusion. Contraception 2015; 92:124-7. [PMID: 25592081 DOI: 10.1016/j.contraception.2015.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/04/2014] [Accepted: 01/05/2015] [Indexed: 11/21/2022]
Abstract
Permanent contraception with hysteroscopic tubal ligation is an increasingly popular choice for women around the world. However, inconveniences associated with the required confirmation test for tubal occlusion can be prohibitive. As new methods of permanent contraception are being investigated, ways of making all aspects of the procedure more accessible and comfortable for women should be considered. Means of examining tubal patency in the infertility population, such as tubal perfusion pressures measured at the time of hysterosalpingogram (HSG), provide inspiration for alternative methods of tubal occlusion confirmation after contraception. Evaluation of intrauterine pressures measured by a manometer attached to an intrauterine balloon catheter could serve as a preliminary tool for verification of tubal occlusion; higher pressures would indicate tubal occlusion and lower pressures would indicate the need for confirmatory HSG. The development and validation of this technique is ongoing and could reduce overall costs and patient burdens associated with the current tubal occlusion confirmation procedure.
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Arjona Berral JE, Rodríguez Jiménez B, Velasco Sánchez E, Povedano Cañizares B, Monserrat Jordan J, Lorente Gonzalez J, Castelo-Branco C. Essure®and chronic pelvic pain: A population-based cohort. J OBSTET GYNAECOL 2014; 34:712-3. [DOI: 10.3109/01443615.2014.920795] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Probability of pregnancy after sterilization: a comparison of hysteroscopic versus laparoscopic sterilization. Contraception 2014; 90:174-81. [PMID: 24767963 DOI: 10.1016/j.contraception.2014.03.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 03/11/2014] [Accepted: 03/16/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the expected probability of pregnancy after hysteroscopic versus laparoscopic sterilization based on available data using decision analysis. STUDY DESIGN We developed an evidence-based Markov model to estimate the probability of pregnancy over 10 years after three different female sterilization procedures: hysteroscopic, laparoscopic silicone rubber band application and laparoscopic bipolar coagulation. Parameter estimates for procedure success, probability of completing follow-up testing and risk of pregnancy after different sterilization procedures were obtained from published sources. RESULTS In the base case analysis at all points in time after the sterilization procedure, the initial and cumulative risk of pregnancy after sterilization is higher in women opting for hysteroscopic than either laparoscopic band or bipolar sterilization. The expected pregnancy rates per 1000 women at 1 year are 57, 7 and 3 for hysteroscopic sterilization, laparoscopic silicone rubber band application and laparoscopic bipolar coagulation, respectively. At 10 years, the cumulative pregnancy rates per 1000 women are 96, 24 and 30, respectively. Sensitivity analyses suggest that the three procedures would have an equivalent pregnancy risk of approximately 80 per 1000 women at 10 years if the probability of successful laparoscopic (band or bipolar) sterilization drops below 90% and successful coil placement on first hysteroscopic attempt increases to 98% or if the probability of undergoing a hysterosalpingogram increases to 100%. CONCLUSION Based on available data, the expected population risk of pregnancy is higher after hysteroscopic than laparoscopic sterilization. Consistent with existing contraceptive classification, future characterization of hysteroscopic sterilization should distinguish "perfect" and "typical" use failure rates. IMPLICATIONS Pregnancy probability at 1 year and over 10 years is expected to be higher in women having hysteroscopic as compared to laparoscopic sterilization.
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Ahlborg L, Hedman L, Nisell H, Felländer-Tsai L, Enochsson L. Simulator training and non-technical factors improve laparoscopic performance among OBGYN trainees. Acta Obstet Gynecol Scand 2014; 92:1194-201. [PMID: 24461067 DOI: 10.1111/aogs.12218] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 07/10/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate how simulator training and non-technical factors affect laparoscopic performance among residents in obstetrics and gynecology. DESIGN In this prospective study, trainees were randomized into three groups. The first group was allocated to proficiency-based training in the LapSimGyn(®) virtual reality simulator. The second group received additional structured mentorship during subsequent laparoscopies. The third group served as control group. At baseline an operation was performed and visuospatial ability, flow and self-efficacy were assessed. All groups subsequently performed three tubal occlusions. Self-efficacy and flow were assessed before and/or after each operation. SETTING Simulator training was conducted at the Center for Advanced Medical Simulation and Training, Karolinska University Hospital. Sterilizations were performed at each trainee's home clinic. POPULATION Twenty-eight trainees/residents from 21 hospitals in Sweden were included. METHODS/MAIN OUTCOME MEASURES Visuospatial ability was tested by the Mental Rotation Test-A. Flow and self-efficacy were assessed by validated scales and questionnaires. Laparoscopic performance was measured as the duration of surgery. Visuospatial ability, self-efficacy and flow were correlated to the laparoscopic performance using Spearman's correlations. Differences between groups were analyzed by the Mann-Whitney U-test. RESULTS No differences across groups were detected at baseline. Self-efficacy scores before and flow scores after the third operation were significantly higher in the trained groups. Duration of surgery was significantly shorter in the trained groups. Flow and self-efficacy correlate positively with laparoscopic performance. CONCLUSIONS Simulator training and non-technical factors appear to improve the laparoscopic performance among trainees/residents in obstetrics and gynecology.
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Affiliation(s)
- Liv Ahlborg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden; Center for Advanced Medical Simulation and Training (CAMST), Karolinska University Hospital, Stockholm, Sweden; Department of Obstetrics and Gynecology, Södertälje Hospital, Södertälje, Sweden; Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
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Leyser-Whalen O, Berenson AB. Control and constraint for low-income women choosing outpatient sterilization. QUALITATIVE HEALTH RESEARCH 2013; 23:1114-24. [PMID: 23761929 PMCID: PMC3708999 DOI: 10.1177/1049732313494483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Little is known about Hispanics and their contraceptive choices in general, with some past studies detailing nonconsensual sterilization. This article is based on interviews with a mostly Hispanic sample of 44 women being sterilized at a public clinic in southeast Texas with the Essure device, which entails a new outpatient sterilization procedure. The women cited relationship factors, wanting to better their and their children's lives, and past reproductive histories as reasons for deciding on sterilization. They specifically chose Essure as a result of an apprehension of surgery and potential side effects from tubal ligation. Their choices, however, were limited by larger structural factors of work, family, the political economy, and the health care system. We concluded that this new sterilization technique provided more contraceptive choices for these women, yet more contraceptive decision-making autonomy and more equitable social structures are still needed.
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Affiliation(s)
- Ophra Leyser-Whalen
- Department of Sociology and Anthropology, University of Texas at El Paso, El Paso, Texas 79968, USA.
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Depes DDB, Pereira AMG, Yatabe S, Lopes RGC. Hysteroscopic sterilization of patient with intrauterine device Mirena®. EINSTEIN-SAO PAULO 2013; 11:108-10. [PMID: 23579753 PMCID: PMC4872978 DOI: 10.1590/s1679-45082013000100019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 01/26/2012] [Indexed: 11/23/2022] Open
Abstract
Tubal sterilization is the definitive procedure most often used worldwide to control fecundity. Laparoscopic ligature is safe, but invasive and with possible surgical and anesthetic risks. The hysteroscopic approach enables tubal occlusion at outpatient's setting without the need of incisions or anesthesia. A microdevice (Essure®) is inserted directly into the tubes and its polyethelene fibers cause obstruction of tubes in about three months. During this period, it is recommended that patients continue the use of a temporary birth control method. Several women use the levonorgestrel-releasing intrauterine system, which is called in the market as Mirena®. This report evaluated the possibility of inserting Essure® without remove the intrauterine device; patient tolerance to the procedure was also assessed. The tubal device was successfully placed in the patient without the need to remove Mirena®. After three months the intrauterine device was removed with no intercurrent events.
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Haimovich S, Mancebo G, Alameda F, Agramunt S, Hernández JL, Carreras R. Endometrial preparation with desogestrel before Essure hysteroscopic sterilization: preliminary study. J Minim Invasive Gynecol 2013; 20:591-4. [PMID: 23587906 DOI: 10.1016/j.jmig.2013.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/03/2013] [Accepted: 03/05/2013] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To assess the effect of desogestrel on endometrial preparation for transcervical sterilization using the Essure device. DESIGN Prospective nonrandomized clinical study (Canadian Task Force classification II-3). SETTING Acute-care university-affiliated hospital in Barcelona, Spain. PATIENTS Women undergoing sterilization using the Essure device between January 2010 and January 2011. INTERVENTIONS Participants were offered desogestrel, 75 μg/d, for 6 weeks before the procedure. Sixteen who accepted were included in the desogestrel group, and 18 who refused were allocated to the no-treatment group. Endometrial biopsy samples were also obtained. MEASUREMENTS AND MAIN RESULTS In women who received desogestrel, decidual transformation was observed in eight, glandular atrophy in three, and proliferative endometrium in five. In the no-treatment group, two women had menstruation, nine had proliferative endometrium, and seven had secretory endometrium. In the desogestrel group, the procedure was successful in all women. In the no-treatment group, the procedure was cancelled in two women because of menstruation and in four women with secretory endometrium in whom the tubal ostia were difficult to visualize because of endometrial thickness and bleeding. The median (interquartile range, 25th-75th percentile) duration of the procedure was shorter in the desogestrel group than in the no-treatment group (7 [6-7] minutes vs 8 [7-12] minutes; p = .002). CONCLUSION Desogestrel, 75 μg/d, could be an alternative to combined hormonal contraception before placement of Essure inserts, facilitating the procedure and serving as a contraceptive method during the following 12 weeks until occlusion of the tubes.
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Affiliation(s)
- Sergio Haimovich
- Service of Obstetrics and Gynecology, Hospital Universitari Parc de Salut Mar, Auniversitat Autònoma de Barcelona, Barcelona, Spain.
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Mantel HT, Wijma J, Stael AP. Small bowel obstruction and perforation after Essure sterilization: a case report. Contraception 2013; 87:121-3. [DOI: 10.1016/j.contraception.2012.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 07/07/2012] [Accepted: 07/12/2012] [Indexed: 11/26/2022]
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Howard DL, Wall J, Strickland JL. What are the Factors Predictive of Hysterosalpingogram Compliance After Female Sterilization by the Essure Procedure in a Publicly Insured Population? Matern Child Health J 2012; 17:1760-7. [DOI: 10.1007/s10995-012-1195-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Chapa HO, Antonetti AG, Bakker K. Essure Sterilization in Patients with History of Pelvic Inflammatory Disease and Hydrosalpinges: An Analysis on Feasibility and Clinical Outcomes. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2010.0110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hector O. Chapa
- Women's Specialty Center and Department of Obstetrics/Gynecology, Methodists Medical Center, Dallas, TX
| | - Alfred G. Antonetti
- Women's Specialty Center and Department of Obstetrics/Gynecology, Methodists Medical Center, Dallas, TX
| | - Ken Bakker
- Women's Specialty Center and Department of Obstetrics/Gynecology, Methodists Medical Center, Dallas, TX
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Chapa HO, Venegas G. Preprocedure patient preferences and attitudes toward permanent contraceptive options. Patient Prefer Adherence 2012; 6:331-6. [PMID: 22563241 PMCID: PMC3340118 DOI: 10.2147/ppa.s30247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To determine patient preference for laparoscopic tubal occlusion or hysteroscopic tubal occlusion, two common sterilization interventions, and the acceptability of a postprocedure confirmation test for a hysteroscopic approach. PARTICIPANTS AND METHODS A total of 100 patients were offered two procedures. A description of each procedure was developed and read to each patient by a research nurse on site. Patients were then asked to respond to a questionnaire concerning options. Final informed consent, procedure review, and procedural date determination were provided by a physician upon completion of the questionnaire. Patients were not allowed to change their questionnaire responses after completion. No interviewer or physician input was allowed during the questionnaire. The study was completed in English or Spanish, as per patient request, by a bilingual/fluent speaker. Physicians completing informed consent were unaware of the questionnaire responses. Patients were not financially incentivized. RESULTS Of 100 participants, 93 (93%) preferred hysteroscopic sterilization to laparoscopy. The reasons were as follows: fear of general anesthesia (24/93 [26%]), fear of incision (25/93 [27%]), cost (32/93 [34%]), and time (12/93 [13%]) to return to routine activity. All 93 viewed "office-based location" as the main advantage over laparoscopy; 88/93 (94.6%) considered a confirmation test to be a benefit of the procedure. After informed consent was obtained, one additional patient switched from a laparoscopic decision to hysteroscopy (total = 94/100); 89/94 (95%) hysteroscopic decisions underwent hysteroscopic sterilization; 4/6 (67%) laparoscopic decisions proceeded to that surgery. The remainder (N = 7) cancelled due to lack of financial resources. CONCLUSION A nonincisional, office-based approach to sterilization has high patient acceptability. Patients viewed a confirmatory test for tubal occlusion as a benefit after sterilization.
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Affiliation(s)
- Hector O Chapa
- Department of Obstetrics and Gynecology, Women’s Specialty Center Dallas, Methodist Medical Center, Dallas, TX, USA
| | - Gonzalo Venegas
- Department of Obstetrics and Gynecology, Women’s Specialty Center Dallas, Methodist Medical Center, Dallas, TX, USA
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Leyser-Whalen O, Rouhani M, Rahman M, Berenson AB. Tubal risk markers for failure to place transcervical sterilization coils. Contraception 2011; 85:384-8. [PMID: 22036044 DOI: 10.1016/j.contraception.2011.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 09/07/2011] [Accepted: 09/08/2011] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Ophra Leyser-Whalen
- Center for Interdisciplinary Research in Women's Health, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX 77555, USA
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Reliability of laparoscopic compared with hysteroscopic sterilization at 1 year: a decision analysis. Obstet Gynecol 2011; 118:273-279. [PMID: 21775842 DOI: 10.1097/aog.0b013e318224d4d2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the probability of successful sterilization after an hysteroscopic or laparoscopic sterilization procedure. METHODS An evidence-based clinical decision analysis using a Markov model was performed to estimate the probability of a successful sterilization procedure using laparoscopic sterilization, hysteroscopic sterilization in the operating room, and hysteroscopic sterilization in the office. Procedure and follow-up testing probabilities for the model were estimated from published sources. RESULTS In the base case analysis, the proportion of women having a successful sterilization procedure on the first attempt is 99% for laparoscopic sterilization, 88% for hysteroscopic sterilization in the operating room, and 87% for hysteroscopic sterilization in the office. The probability of having a successful sterilization procedure within 1 year is 99% with laparoscopic sterilization, 95% for hysteroscopic sterilization in the operating room, and 94% for hysteroscopic sterilization in the office. These estimates for hysteroscopic success include approximately 6% of women who attempt hysteroscopically but are ultimately sterilized laparoscopically. Approximately 5% of women who have a failed hysteroscopic attempt decline further sterilization attempts. CONCLUSION Women choosing laparoscopic sterilization are more likely than those choosing hysteroscopic sterilization to have a successful sterilization procedure within 1 year. However, the risk of failed sterilization and subsequent pregnancy must be considered when choosing a method of sterilization.
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A comparison of novice and experienced physicians performing hysteroscopic sterilization: an analysis of an FDA-mandated trial. Fertil Steril 2011; 96:643-648.e1. [DOI: 10.1016/j.fertnstert.2011.06.047] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 06/15/2011] [Accepted: 06/16/2011] [Indexed: 11/22/2022]
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Connor VF. Clinical experience with contrast infusion sonography as an Essure confirmation test. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:803-808. [PMID: 21632995 DOI: 10.7863/jum.2011.30.6.803] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the clinical experience, including the feasibility, safety, compliance, and efficacy, of contrast infusion sonography as an Essure (Conceptus Inc, Mountain View, CA) confirmation test. METHODS A retrospective chart review and telephone survey were conducted at an academic multispecialty group. The study participants were women with Essure intervention who underwent contrast infusion sonography, transvaginal sonography, and hysterosalpingography as Essure confirmation tests. The main outcome measures included the feasibility, safety, compliance, and efficacy of contrast infusion sonography as a first-line Essure confirmation test. RESULTS A total of 118 women had successful bilateral Essure placement. Of the 63 who consented to contrast infusion sonography, 53 (84.1%) had proper bilateral placement and tubal occlusion and were encouraged to rely on Essure. Four were suspected of having unilateral tubal patency; hysterosalpingography in 2 confirmed bilateral tubal occlusion, and 2 were noncompliant with second-line hysterosalpingography. Three patients suspected of having unsatisfactory or uncertain placement on initial transvaginal sonography were encouraged to undergo hysterosalpingography in lieu of contrast infusion sonography, which confirmed unsatisfactory placement in 2 and proper placement and occlusion in 1. Three contrast infusion sonographic procedures could not be completed because of technical issues; therefore, contrast infusion sonography was feasible in 95.2% of the patients (60 of 63). No notable adverse events occurred. Only 17 patients were noncompliant with any confirmation test, yielding an overall compliance rate of 86% (101 of 118). No pregnancies occurred during 669 woman-months of follow-up. The average reimbursement for contrast infusion sonography was US$251.78. CONCLUSIONS Preliminary clinical data suggest that contrast infusion sonography is a feasible, safe, and accurate Essure confirmation test, which is well accepted by patients.
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Affiliation(s)
- Viviane F Connor
- Department of Gynecology, Section of Minimally Invasive Gynecology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA.
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Moawad N, Mansuria S. Essure Perforation and Chronic Pelvic Pain. J Minim Invasive Gynecol 2011; 18:285-6. [DOI: 10.1016/j.jmig.2010.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 03/11/2010] [Accepted: 03/18/2010] [Indexed: 10/18/2022]
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March CM. Tubal Sterilization. Contraception 2011. [DOI: 10.1002/9781444342642.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Thiel J, Suchet I, Tyson N, Price P. Outcomes in the Ultrasound Follow-up of the Essure Micro-Insert: Complications and Proper Placement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:134-138. [DOI: 10.1016/s1701-2163(16)34798-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Shah V, Panay N, Williamson R, Hemingway A. Hysterosalpingogram: an essential examination following Essure hysteroscopic sterilisation. Br J Radiol 2010; 84:805-12. [PMID: 21123309 DOI: 10.1259/bjr/95330860] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- V Shah
- Department of Imaging, Hammersmith and Queen Charlotte Hospitals, Imperial College Healthcare NHS Trust, London, UK.
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Tubal sterilization trends in the United States. Fertil Steril 2010; 94:1-6. [DOI: 10.1016/j.fertnstert.2010.03.029] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/09/2010] [Indexed: 11/24/2022]
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Smith RD. Contemporary hysteroscopic methods for female sterilization. Int J Gynaecol Obstet 2009; 108:79-84. [DOI: 10.1016/j.ijgo.2009.07.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 07/20/2009] [Indexed: 11/16/2022]
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Connor VF. Essure: A Review Six Years Later. J Minim Invasive Gynecol 2009; 16:282-90. [DOI: 10.1016/j.jmig.2009.02.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 02/08/2009] [Accepted: 02/18/2009] [Indexed: 10/20/2022]
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