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

Current techniques and outcomes in hysteroscopic sterilization: current evidence, considerations, and complications with hysteroscopic sterilization micro inserts

PURPOSE OF REVIEW

To describe the current data regarding effectiveness, complications, postoperative evaluation, and surgical interventions associated with Essure hysteroscopic sterilization.

RECENT FINDINGS

Hysteroscopic sterilization is a commonly performed procedure that is offered as a well tolerated, effective, outpatient method of permanent sterilization. Over the past several years, concerns have been raised regarding correct placement and postoperative complications. This has led to statements by both the Food and Drug Administration (FDA) in October, 2016 and American Association of Gynecologic Laparoscopists in February, 2017, as a significant portion of women seek removal of these devices. A current black-box warning issued by the FDA in 2016 recommends discussion of 'the probabilities of rates or events' of adverse outcomes associated with Essure placement.

SUMMARY

Although hysteroscopic sterilization is usually a safe, effective option for permanent contraception, new evidence regarding complications has emphasized the need for proper education and counseling. Appropriate patient selection and knowledge of potential complications is paramount to ensuring patients, and medical providers are well informed and have realistic expectations regarding potential placement and postoperative issues.

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

Objective

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

Methods

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

Results

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

Conclusion

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

The effect of obesity on intraoperative complication rates with hysteroscopic compared to laparoscopic sterilization: a retrospective cohort study

Background

Surgical sterilization is a common method of contraception. There have been few studies evaluating the effect of obesity on procedural complications with either laparoscopic or hysteroscopic methods of sterilization. The purpose of this study was to compare the incidence of intraoperative complications of hysteroscopic tubal occlusion with laparoscopic tubal ligation among obese and nonobese women.

Methods

This retrospective cohort study compared women undergoing interval laparoscopic or hysteroscopic sterilization in the operating room between September 2009 and December 2011 at a single hospital. Serious complications included: unintended surgery, uterine perforation, anaphylaxis, blood transfusion, infection requiring antibiotics, hospital admission, fluid overload, myocardial infarction, and venous thromboembolism. Post-operative events included: nausea/vomiting, doctor evaluation or additional pain medication required in the recovery room, and emergency department visit within 2 weeks of surgery. The association between sterilization type and incidence of complications was examined overall, separately by BMI group, and also among patients who received general anesthesia.

Results

A total of 433 laparoscopic and 277 hysteroscopic procedures were reviewed. The BMI distribution of the sample was 35 % normal weight, 31 % overweight, and 34 % obese which is comparable to the general US female population. No life-threatening events were identified. Serious complications were similar with 20 (4.6 %) in the laparoscopic group and 11 (4.0 %) in the hysteroscopic group (p = 0.9). The most common serious complications were bleeding from the tube, cervical laceration, and uterine perforation. Although not statistically significant, women with a BMI of 30 or greater had only 1 (1 %) serious complication in the hysteroscopic group compared to 7 (5.2 %) in the laparoscopic group. Postoperative events were increased in the laparoscopic group (16.2 %) compared to the hysteroscopic group (6.9 %), especially among overweight and obese women (p <0.01). Failure to complete the intended bilateral occlusion occurred for 14 women in the hysteroscopic group compared to just one woman in the laparoscopic group (p <0.001).

Conclusion

Both laparoscopic and hysteroscopic tubal sterilization are safe with few serious complications based on these data. No cases of laparotomy, blood transfusion, or life-threatening events were identified. There was no difference in serious complication rate by sterilization method. Overweight and obese women were no more likely to experience a serious complication with either method than women with a BMI <25. There were fewer postoperative events (p <0.01) with hysteroscopic sterilization, but far fewer failed laparoscopic procedures (p <0.001). These study findings can be used to enhance sterilization counseling.

Contraceptive failure after hysteroscopic sterilization: Analysis of clinical and demographic data from 103 unplanned pregnancies

Objective

This investigation examined data on unplanned pregnancies following hysteroscopic sterilization (HS).

Methods

A confidential questionnaire was used to collect data from women with medically confirmed pregnancy (n=103) registered after undergoing HS.

Results

Mean (±SD) patient age and body mass index (BMI) were 29.5±4.6 years and 27.7±6.1 kg/m², respectively. Peak pregnancy incidence was reported at 10 months after HS, although <3% of unplanned pregnancies occurred within the first three months following HS. Mean (±SD) interval between HS and pregnancy was 19.6±14.9 (range, 2 to 84) months. Patients age ≥30 years and BMI <25 reported conception after HS somewhat sooner than younger patients, although the differences in time to pregnancy were not significant (P=0.24 and 0.09, respectively). The recommended post-HS hysterosalpingogram (to confirm proper placement and bilateral tubal occlusion) was obtained by 66% (68/103) of respondents.

Conclusion

This report is the first to provide patient-derived data on contraceptive failures after HS. While adherence to backup contraception 3 months after HS can be poor, many unintended pregnancies with HS occur long after the interval when alternate contraceptive is required. Many patients who obtain HS appear to ignore the manufacturer's guidance regarding the post-procedure hysterosalpingogram to confirm proper device placement, although limited insurance coverage likely contributes to this problem. The greatest number of unplanned pregnancies occurred 10 months after HS, but some unplanned pregnancies were reported up to 7 years later. Age, BMI, or surgical history are unlikely to predict contraceptive failure with HS. Further follow-up studies are planned to capture additional data on this issue.