Essure: A Review Six Years Later

The plasticity of biocompatibility

Biocompatibility concerns the phenomena that occur within the interactions between biomaterials and human patients, which ultimately control the performance of many facets of medical technology. It involves aspects of materials science, many different forms of engineering and nanotechnology, chemistry, biophysics, molecular and cellular biology, immunology, pathology and a myriad of clinical applications. It is not surprising that an overarching framework of mechanisms of biocompatibility has been difficult to elucidate and validate. This essay discusses one fundamental reason for this; we have tended to consider biocompatibility pathways as essentially linear sequences of events which follow well-understood processes of materials science and biology. The reality, however, is that the pathways may involve a great deal of plasticity, in which many additional idiosyncratic factors, including those of genetic, epigenetic and viral origin, exert influence, as do complex mechanical, physical and pharmacological variables. Plasticity is an inherent core feature of the performance of synthetic materials; here we follow the more recent biological applications of plasticity concepts into the sphere of biocompatibility pathways. A straightforward linear pathway may result in successful outcomes for many patients; we may describe this in terms of classic biocompatibility pathways. In other situations, which usually command much more attention because of their unsuccessful outcomes, these plasticity-driven processes follow alternative biocompatibility pathways; often, the variability in outcomes with identical technologies is due to biological plasticity rather than material or device deficiency.

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.

Symptom related to Essure® and evolution after removal: Outcomes of retrospective cohort

INTRODUCTION

The number of requests for Essure removal has grown continually over recent years. The objective is to describe the symptoms reported after Essure sterilization, methods of removal and results.

MATERIAL AND METHODS

Retrospective and single-centre cohort (Regional university hospital of Lille, France) was conducted. All women, having consulted from December 2016 to February 2019 for symptoms related to Essure insertion, were included. All the symptoms were noted. A second group was created that included patients who underwent Essure removal to evaluate the benefits of surgery on these symptoms.

RESULTS

The study included 98 patients. Most frequent symptoms were musculoskeletal pain (75 %), asthenia (63 %) and pelvic pain (55 %). Fifty-nine patients (60 %) underwent surgery. Surgery appeared beneficial with reduction of symptoms in 60 % of these patients, complete resolution in 33 % and no reduction of symptoms in 7%. Many symptoms were relieved by surgery with an overall decline of 96 % in menorrhagia, 94 % in metrorrhagia and 93 % in dyspareunia. However, other symptoms were not relieved by surgery like 100 % of sleep disorders, 70 % of abdominal pain cases and 57 % of memory impairment cases.

CONCLUSION

Symptoms related to Essure insertion are numerous. Although surgery appears beneficial, some adverse effects remain. Therefore, a preoperative aetiologic assessment and information about risk of surgery failure are important.

Saline-Air Hysterosalpingo-Contrast Sonography Is Equivalent to the Modified Hysterosalpingogram Following Hysteroscopic Sterilization

PURPOSE

To estimate the diagnostic efficacy of saline-air hysterosalpingo-contrast sonography (SA-HyCoSy) compared with the modified hysterosalpingogram (mHSG) for confirmation of both coil location and tubal occlusion following hysteroscopic sterilization.

METHODS

This study included 19 women who underwent both SA-HyCoSy and mHSG where 1 test was followed by the other. Sensitivity, specificity, and positive and negative predictive values for tubal occlusion against the mHSG were calculated for each fallopian tube by 2 independent interpreters. Interrater reliability was assessed using Cohen κ statistic. Procedure time and pain level by 11-point numeric rating scale of SA-HyCoSy and mHSG were also compared.

RESULTS

Thirty-eight fallopian tubes were evaluated. Tubal occlusion was noted in 97.3% of tubes for both interpreters with the mHSG compared with 92.1% and 94.7% with SA-HyCoSy. The positive and negative predictive values for tubal occlusion were 100%/100% and 50%/33%, respectively, with an overall agreement of 97.4% and 95.7%, κ = 0.48, P < 0.01. Saline-air HyCoSy changed interpretation of coil insert location in 50% and 44.7% for each interpreter, being downgraded from optimal to satisfactory in 42.9% (9/21) and 36% (9/25) and upgraded to optimal in 58.8% (10/17) and 61.5% (8/13), respectively. There were no statistically significant differences in procedural time (7.5 vs 9.4 minutes, P > 0.05) or maximum pain scores (2.3 vs 3.1, P > 0.05) for the mHSG compared with SA-HyCoSy.

CONCLUSIONS

Our findings revealed a high degree of diagnostic accuracy with SA-HyCoSy for tubal occlusion, although coil location changed in nearly half of cases. Avoidance of radiation and patient convenience/compliance with SA-HyCoSy may outweigh the drawbacks.

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.

Factors Associated with Negative Patient Experiences with Essure Sterilization

Study Objective:

The objective of the study was to identify factors associated with negative patient experiences with Essure.

Design:

This was a retrospective cohort study and follow-up survey.

Setting:

The study was conducted in an academic setting.

Patients:

Patients included women who had an Essure placed between 2002 and 2017.

Methods:

The hospitals' database was queried to identify subjects and charts were reviewed to confirm medical information. Subjects were invited by mail, e-mail, or phone call to participate a survey regarding symptoms and satisfaction with Essure. A comparison was made between women who reported a negative experience with Essure versus those who did not. A multivariable logistic regression analysis was performed to identify subject or procedural characteristics associated with any negative experience with Essure sterilization.

Results:

Two hundred eighty-four women underwent Essure sterilization between 2002 and 2017, 42.3% of whom responded to the follow-up survey. Satisfaction with Essure was reported by 61.9% of respondents. Thirty-three percent of the respondents have undergone removal or desire removal of the device. The most frequent symptoms attributed to Essure were pelvic pain, dyspareunia, and vaginal bleeding. Forty-eight percent of the respondents were identified as having any negative experience with Essure. Factors associated with negative experiences with Essure included young age at placement (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.79–0.94; P < .001), high gravidity (OR 1.39; 95% CI 1.14–1.71; P = .002), and absent history of abdominal surgery (OR 0.35; 95% CI 0.12–1.00; P = .049).

Conclusion:

Young age at placement, high gravidity, and absent history of abdominal surgery are factors associated with negative patient experiences following Essure sterilization. A negative experience with Essure is common, although dissatisfaction with the device is not always attributable to symptoms. This information could be considered when counseling women who plan removal of Essure.

Implications Statement:

Our study provides new follow-up data with respect to hysteroscopic sterilization. This research is the first to examine any cause for negative patient experiences with Essure. Understanding factors associated with negative patient experiences could improve patient counseling regarding the extent to which symptoms could be attributed to Essure as well as counseling women who want to undergo removal of the device. These factors could in turn prove to be predictors for successful resolution of symptoms after removal of Essure. Results of this study could also be used for developing future hysteroscopic sterilization techniques.

One-step transvaginal three-dimensional hysterosalpingo-foam sonography (3D-HyFoSy) confirmation test for Essure® follow-up: a multicenter study

OBJECTIVE

To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic insertion of an Essure® device, the feasibility and accuracy of three-dimensional (3D) transvaginal sonography (TVS) to check the position of the device and 3D hysterosalpingo-foam sonography (3D-HyFoSy) using contrast-enhanced gel foam to assess consequent tubal occlusion.

METHODS

This was a prospective multicenter study conducted from June 2012 to July 2014 in four Italian centers, which included 50 women who underwent hysteroscopic Essure microinsert placement in a total of 95 Fallopian tubes. Placement of the microinserts was performed in an outpatient setting following standard procedure recommendations. All patients underwent transvaginal 3D-HyFoSy and hysterosalpingography (HSG) approximately 12-14 weeks after the procedure. The position of the devices was first checked on 3D-TVS and classified according to specific criteria (Positions A, B, C and D). Then, 3D-HyFoSy with ExEm® gel foam as the ultrasound contrast agent was performed to confirm tubal occlusion by the absence of contrast agent within the tubes and/or around the ovaries. To evaluate the feasibility of 3D-HyFoSy, consecutive volume acquisitions were performed while injecting the gel foam. After sonographic evaluation, women underwent HSG to assess the success of sterilization, as standard methodology. Side effects and pain evoked during and after 3D-HyFoSy and HSG were evaluated using a numeric pain rating scale.

RESULTS

On 3D-TVS, 10 devices (10.5%) were in Position A, two (2.1%) in Position B, 59 (62.1%) in Position C and 24 (25.3%) in Position D. During 3D-HyFoSy, tubal occlusion was observed in 89 of 95 tubes (93.7%). In the six cases in which the passage of the contrast was observed, one device (16.7%) was in Position B, one device (16.7%) in Position D and four devices (66.7%) were found to lie in Position C. Tubal patency was confirmed at HSG with a concordance rate of 100%. The mean pain score associated with 3D-HyFoSy was significantly lower than that on HSG.

CONCLUSIONS

3D-TVS with HyFoSy allows accurate assessment of the position of Essure microinserts and tubal occlusion. It can be considered a safe, reliable, non-invasive alternative to HSG. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

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.).

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.

Safety and efficacy of hysteroscopic sterilization compared with laparoscopic sterilization: an observational cohort study

OBJECTIVE

To compare the safety and efficacy of hysteroscopic sterilization with the "Essure" device with laparoscopic sterilization in a large, all-inclusive, state cohort.

DESIGN

Population based cohort study.

SETTINGS

Outpatient interventional setting in New York State.

PARTICIPANTS

Women undergoing interval sterilization procedure, including hysteroscopic sterilization with Essure device and laparoscopic surgery, between 2005 and 2013.

MAIN OUTCOMES MEASURES

Safety events within 30 days of procedures; unintended pregnancies and reoperations within one year of procedures. Mixed model accounting for hospital clustering was used to compare 30 day and 1 year outcomes, adjusting for patient characteristics and other confounders. Time to reoperation was evaluated using frailty model for time to event analysis.

RESULTS

We identified 8048 patients undergoing hysteroscopic sterilization and 44,278 undergoing laparoscopic sterilization between 2005 and 2013 in New York State. There was a significant increase in the use of hysteroscopic procedures during this period, while use of laparoscopic sterilization decreased. Patients undergoing hysteroscopic sterilization were older than those undergoing laparoscopic sterilization and were more likely to have a history of pelvic inflammatory disease (10.3% v 7.2%, P<0.01), major abdominal surgery (9.4% v 7.9%, P<0.01), and cesarean section (23.2% v 15.4%, P<0.01). At one year after surgery, hysteroscopic sterilization was not associated with a higher risk of unintended pregnancy (odds ratio 0.84 (95% CI 0.63 to 1.12)) but was associated with a substantially increased risk of reoperation (odds ratio 10.16 (7.47 to 13.81)) compared with laparoscopic sterilization.

CONCLUSIONS

Patients undergoing hysteroscopic sterilization have a similar risk of unintended pregnancy but a more than 10-fold higher risk of undergoing reoperation compared with patients undergoing laparoscopic sterilization. Benefits and risks of both procedures should be discussed with patients for informed decisions making.

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.

Hysterosalpingography After Radiofrequency Endometrial Ablation and Hysteroscopic Sterilization as a Concomitant Procedure

OBJECTIVE

To evaluate the accuracy of hysterosalpingography (HSG) in patients who underwent concomitant radiofrequency endometrial ablation and hysteroscopic sterilization.

METHODS

This historical cohort study was conducted at a midwestern academic medical center. A total of 186 women (94 with combined procedure and 92 with sterilization alone) were identified as having undergone intervention between January 1, 2003, and June 30, 2011. Two reviewers blinded to the surgical procedure interpreted the standard clinically indicated HSGs in each group.

RESULTS

The primary outcome assessed was the inability to rely on the microinserts for contraception based on HSG interpretation using manufacturers' guidelines (unsatisfactory HSG). Position of the devices and occlusion of tubes were assessed on all 3-month and, when available, all 6-month repeat HSGs. At the 3-month HSG, 5 of 76 (6.6%, 95% confidence interval [CI] 2.2-14.7%) in the sterilization-only group had unsatisfactory HSG compared with 13 of 71 (18.3%, 95% CI 10.1-29.3%) in the combined group (P=.03). After accounting for the seven patients who underwent repeat HSG at 6 months, 3 of 76 (3.95%, 95% CI 0.8-11.1%) in the sterilization-only group had unsatisfactory HSG compared with 13 of 71 (18.31%, 95% CI 10.1-29.3%) in the combined group (P=.005).

CONCLUSION

After completing all clinically indicated HSGs, patients who undergo concomitant radiofrequency endometrial ablation and hysteroscopic sterilization have an approximate fivefold increase (odds ratio 5.45, 95% CI 1.48-20.0) in the rate of unsatisfactory HSG for purposes of documenting tubal occlusion.

LEVEL OF EVIDENCE

II.

Evaluation of tubal microinserts position using 3D ultrasound and pelvic X-ray

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.

Hysteroscopy and contraception

The Essure method is the only available hysteroscopic sterilisation method. A 4-cm device is placed in the fallopian tubes, which then induces an inflammatory reaction that causes occlusion. The method has a high successful placement rate and high effectiveness, and it can be performed in an office setting without anaesthesia. Three months after the procedure, a confirmation test has to be conducted to assure a correct position of the micro-inserts and tubal occlusion. This test can be performed by hysterosalpingography (HSG), plain X-ray or ultrasound. Pregnancies reported after Essure sterilisation are, in a majority, related to non-adherence to the follow-up protocol or misreading of the confirmation test. A majority of the pregnancies occurred after HSGs that were determined to have been misinterpreted, including missed expulsion or perforation of the micro-insert. Other complications such as ectopic pregnancy and allergic reaction to the micro-inserts seem to have been described to be of low incidence.

Incidence and risk factors for chronic pelvic pain after hysteroscopic sterilization

STUDY OBJECTIVE

To investigate the incidence of and preoperative risk factors for developing pelvic pain after hysteroscopic sterilization using the Essure microinserts.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

University medical center.

PATIENTS

A total of 458 patients who underwent hysteroscopic sterilization using Essure between January 1, 2005, and June 30, 2012.

INTERVENTION

Hysteroscopic sterilization using Essure.

MEASUREMENTS AND MAIN RESULTS

The incidence of acute pelvic pain after hysteroscopic sterilization was 8.1%, and of persistent pain at 3 months after the procedure was 4.2%. The range of presence of pain was 1 to 469 days (mean, 56 days). Of patients who developed chronic pelvic pain after the procedure, 75% reported it within 130 days of the procedure. Patients with previous diagnoses of any chronic pain (chronic pelvic pain, chronic low back pain, chronic headache, and fibromyalgia) were more likely to report both acute pain (odds ratio, 6.81; 95% confidence interval, 2.95-15.73) and chronic pain (odds ratio, 6.15; 95% confidence interval, 2.10-18.10) after hysteroscopic sterilization.

CONCLUSIONS

Pelvic pain may develop after hysteroscopic sterilization. Patients with a diagnosis of preexisting chronic pain may be at increased risk of developing pelvic pain after the procedure. Fifty percent of new pelvic pain after Essure placement will resolve within 3 months.

Probability of pregnancy after sterilization: a comparison of hysteroscopic versus laparoscopic sterilization

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.

Control and constraint for low-income women choosing outpatient sterilization

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.

Hysteroscopic sterilization success in outpatient vs office setting is not affected by patient or procedural characteristics

STUDY OBJECTIVE

To determine factors associated with hysteroscopic sterilization success and whether it differs between the operating room and office settings.

DESIGN

Retrospective cohort analysis (Canadian Task Force classification II-2).

SETTING

Major university medical center.

PATIENTS

Six hundred thirty-eight women who underwent hysteroscopic sterilization between July 1, 2005, and June 30, 2011.

MEASUREMENTS AND MAIN RESULTS

Data collected included age, body mass index, previous office procedures, previous cesarean section, and presence of myomas or retroverted uterus. Place of surgery, experience of surgeon, insurance type, bilateral device placement, compliance with hysterosalpingography, and confirmation of occlusion were also recorded. Bivariate analysis of patient characteristics between groups was performed using χ(2) and independent t tests, and identified confounders and associated variables. Multivariate analysis was performed using logistic regression to assess for association and to adjust for confounders. Procedures were performed in the operating room (57%) or in the office (43%). There was no association between success in bilateral device placement or occlusion and any patient characteristic, regardless of surgery setting. Private insurance, patient age, and performance of procedures in the office setting were positively associated with likelihood of compliance with hysterosalpingography.

CONCLUSION

Successful device placement and tubal occlusion are independent of patient age, body mass index, or setting of the procedure. Association between insurance type and completing hysterosalpingography illustrates an important public health problem. Patients who fail to undergo hysterosalpingography to confirm tubal occlusion may unknowingly be at risk of pregnancy and increased risk of ectopic pregnancy.

Efficacy of Essure hysteroscopic sterilization--5 years follow up of 1200 women

OBJECTIVE

To assess the efficacy of the Essure hysteroscopic birth control device after 5 years follow up.

STUDY DESIGN

Retrospective analysis of case series.

SETTING

Outpatient hysteroscopy facility in a large teaching hospital.

SUBJECTS

One-thousand three-hundred and twenty-one women who underwent hysteroscopic sterilization with Essure device (Conceptus, Inc., Mountain View, CA) between January 2003 and May 2005.

INTERVENTION(S)

Hysteroscopic tubal sterilization using Essure system.

MAIN OUTCOME MEASURE

Efficacy/effectiveness, failure rate.

RESULTS

Satisfactory insertion was accomplished in the first attempt in 1166 women (97.16%). After the second attempt, successful insertion rate rise to 98.6%. (n = 31, 2.6%). Three pregnancies had been reported after 5 years follow up, which implies an overall absolute rate of 0.25%. This represents a Pearl index of 0.05 after 72,000 months of surveillance. All of them occurred in the first year of use of the microinsert. There has been no unintended pregnancy in the next 4 years.

CONCLUSION(S)

Essure has the lowest Pearl index never published being the most effective permanent birth control system to date. Unintended pregnancies tend to occur in the first year after the insertion, and can be avoided encouraging women to accomplish the protocol.

Endometrial preparation with desogestrel before Essure hysteroscopic sterilization: preliminary study

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.

Preprocedure patient preferences and attitudes toward permanent contraceptive options

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.

Tubal risk markers for failure to place transcervical sterilization coils

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Clinical experience with contrast infusion sonography as an Essure confirmation test

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.