Ultrasound Assessment of the Essure Contraceptive Devices: Is Three-Dimensional Ultrasound Really Needed?

Assessing lateral uterine wall defects and residual myometrial thickness after cesarean section

OBJECTIVE

Lateral wall ruptures in women with a history of cesarean section are less common but more complicated than anterior wall ruptures. Residual myometrial thickness (RMT) is believed to be valuable for assessing the probability of ruptures. This study aimed to assess the utility of OmniView (a sonographic reslicing technique) in evaluating the lateral uterine wall after cesarean section and evaluate the relationship between lateral and anterior wall RMT using OmniView and sagittal two-dimensional ultrasound.

STUDY DESIGN

This cross-sectional study examined changes in both the anterior and lateral uterine wall in women with a history of cesarean section in the past 12-18 months. OmniView with volume contrast imaging with a 2-mm slice thickness was used to generate coronal planes, and the OmniView RMT (OV-RMT) was calculated as a percentage. Blinded to the OV-RMT results, sonographic multiplanar views were used to acquire the optimum sagittal plane for evaluating the RMT, and the sagittal RMT (S-RMT) was calculated as a percentage. The reproducibility of OV-RMT and S-RMT between two observers was tested using interclass correlation (ICC). The relationship between two variables was tested using Spearman's rank correlation.

RESULTS

In 208 recruited patients, the prevalence of lateral uterine wall defects was 79 %. The interobserver and intraobserver reproducibility of S-RMT and OV-RMT had ICC coefficients over 0.9 with a p-value <0.001. S-RMT and OV-RMT did not follow a normal distribution, and the medians were significantly different (55.5 and 85.7, respectively). Spearman's rank correlation between OV-RMT and S-RMT had a rho (ρ) value of 0.24 (p < 0.05). Passing-Bablok regression had an intercept of 47.95 and a slope of 0.65.

CONCLUSION

OmniView can be used to assess lateral uterine wall defects, and OV-RMT is a reproducible and reliable method for quantifying this assessment. The RMT on the coronal plane was independently more intact than that on the sagittal plane, which might account for the lower incidence of lateral ruptures. Further studies could reveal a critical OV-RMT value that is safe for a trial of labor.

Accuracy of Ultrasonography in the Evaluation of Tubal Sterilization Microinsert Positioning: Systematic Review and Meta-analysis

The current reference standard to check the position of a tubal sterilization microinsert device after its insertion is hysterosalpingography. The objective of this study was to evaluate the accuracy of 2-dimensional (2D) and 3-dimensional (3D) ultrasonography (US) in the positioning of the tubal sterilization microinsert for definitive contraception. We searched MEDLINE, Embase, Cochrane, and Scopus databases through October 2017. Selection criteria included studies that analyzed the accuracy of 2D or 3D US, or both, with respect to the positioning of the microinsert. Data were displayed as forest plots and a summary receiver operating characteristic curves. Values for sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated. The pooled analysis produced sensitivity and specificity values for 2D US in the positioning of the microinsert of 0.88 (95% confidence interval [CI], 0.47-1.0) and 0.92 (95% CI, 0.88-0.95), respectively, with positive and negative LRs of 8.68 (95% CI, 1.63-46.1) and 0.35 (95% CI, 0.11-1.11), respectively. Three studies analyzed the performance of 3D US, showing sensitivity, specificity, and positive and negative LRs of 0.75 (95% CI, 0.35-0.97), 0.82 (95% CI, 0.77-0.87), 3.65 (95% CI, 2.31-5.75), and 0.46 (95% CI, 0.2-1.09). In conclusion, 2D and 3D US are methods that show good accuracy in tubal sterilization microinsert positioning.

A Pilot Study Comparing 2- and 3-dimensional Ultrasound Imaging for Confirmation of Essure Fallopian Tube Pregnancy Prevention Implants

STUDY OBJECTIVE

To show the feasibility of 2-dimensional (2D) ultrasound (US) imaging compared with 3-dimensional (3D) US to identify the location of implants and assess if the classification developed by Simorre et al in 2016 was applicable to the 2 types of US imaging (i.e., 2D and 3D).

DESIGN

A prospective study (Canadian Task Force classification II-2).

SETTING

The department of obstetrics and gynecology in a teaching hospital.

PATIENTS

One hundred fifty patients who had undergone hysteroscopic sterilization with Essure (Bayer Pharma AG Laboratory, Lyon, France) fallopian tube pregnancy prevention implants were invited by letter to participate in the study; 50 replied positively between January and August 2017.

INTERVENTIONS

An initial 2D US was performed followed by 3D US reconstruction. The primary end point was to compare the identification of device placement with 2D and 3D US imaging procedures according to this new classification. Secondary considerations were to evaluate the difficulty of attaining images, the quality of implant curvature, the duration of each imaging procedure, and the number of images performed for each technique.

MEASUREMENTS AND MAIN RESULTS

Ninety-six percent of tubal implants were observed via 3D US compared with 100% via 2D US. The mean time of 2D US was 14.64 seconds for the right fallopian tube and 15.25 seconds for the left fallopian tube compared with 25.11 seconds for the right and 31.57 seconds for the left fallopian tube in 3D US (p <.01). The mean number of image acquisitions per patient was 1.02 (±0.14 standard deviation) for 2D US compared with 1.37 (±0.64 standard deviation) for 3D US (p <.01). The sonographer had no difficulty performing 2D US in 88% of cases compared with 58% of 3D US cases.

CONCLUSIONS

Two-dimensional ultrasound appears to be an acceptable alternative to 3D US. We propose a 2D classification for cross section device localization to facilitate image interpretation.

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.

Radiological assessment of the placement of Essure® in order to reduce hysterosalpingography: Pelvic X-ray versus combined pelvic X-ray and ultrasound

OBJECTIVE

Three months after hysteroscopic sterilisation with Essure^®, a confirmation test is required to evaluate the correct location of the inserts. The test may be conducted using a pelvic ultrasound (2D or 3D) or an abdominal X-ray. Should the location not look satisfactory on these tests, a follow-up hysterosalpingography (HSG) would be required. The objective of our study is to assess whether the Essure^® 3-month confirmation test using a single X-ray or a combination of X-ray and ultrasound could reduce the use of HSG.

STUDY DESIGN

This retrospective study examined patients who underwent birth control Essure^® procedure between 2009 and 2015 in the Gynaecological Surgery Department at the Regional University Hospital Centre (CHRU) in Lille. We divided patients into two groups based on the imaging tests performed: single X-ray (2009-2010) versus X-ray and pelvic ultrasound (2014-2015). We then compared the results of the imaging tests and the use of HSG between the two groups.

RESULTS

One hundred and thirty-four patients were tested, of which 60 (44.8%) using a single X-ray and 74 (55.2%) using a combination of X-ray and ultrasound. We note that the combined X-ray/ultrasound test reduces significantly the number of HSG performed (26.7% versus 12.2%, P=0.04).

CONCLUSION

Compared to a single X-ray, the combination of X-ray and ultrasound enables to significantly limit the use of HSG.

Assessment of the uterus with three-dimensional ultrasound in women undergoing ART

BACKGROUND

A detailed assessment of the uterus forms a pivotal part of the ART treatment process. The emergence of three-dimensional ultrasound (3D US) has provided clinicians with a highly powerful tool in this respect. Assessments with 3D US range from the reconstruction of anatomical planes elusive to conventional US, to the objective measurement of anatomical volumes and vascularization parameters. However, despite the ever increasing number of publications emerging in the literature, the question of which aspects of 3D US are of most clinical value remains a topic of debate.

OBJECTIVE AND RATIONALE

The objective of this review is to dissect which aspects of the 3D US assessment of the uterus are supported by a strong level of evidence to date, and should therefore be incorporated into current routine clinical practice.

SEARCH METHODS

We conducted a systematic search of the PubMed database up to May 2016, using a combination of text words and Medical Subject Headings (MeSH) pertaining to the 3D US assessment of the uterus. All articles published in the English language were screened to ascertain relevance to women of reproductive age; further citations were retrieved through manual reference list searching.

OUTCOMES

A multitude of predominantly observational studies were identified, which concerned a vast variety of 3D US uterine assessments. All articles unequivocally praised the non-invasive, cost-effective, highly acceptable and objective nature of 3D US. Studies regarding the value of assessing the endometrial volume and vascularization prior to embryo transfer appeared conflicting and inconsistent. Studies regarding the imaging of uterine pathology and identification of intratubal and intrauterine devices consistently reported high rates of diagnostic accuracy. A recent RCT did not show an improvement in clinical outcomes when comparing 3D versus 2D US during embryo transfer. However, preliminary studies suggested that 3D US is superior in determining the site of implantation, particularly in ambiguous cases such as interstitial and angular pregnancies. Finally, pilot studies have suggested that the further integration of 3D and possibly 4D US with surgical interventions of the uterus may be a promising prospect.

WIDER IMPLICATIONS

3D US may prove to be an invaluable tool in the assessment of the uterus within the context of ART. Currently, the aim should be to highlight the aspects of 3D US that are most evidence-based and valuable for patients, and to incorporate these into routine clinical practice.

[What signs should you look for ultrasound (2D/3D) to affirm the good location of tubal implants? About a retrospective study of 92 cases]

OBJECTIVE

The aim of this study is to propose an analysis of the route and the curvature of the Essure^® system in 3D ultrasound to determine their correct location so as not to miss a tubal perforation.

METHODS

This is a retrospective single center study during 2 years analyzing 92 3D ultrasound performed by a single sonographer. Implant placement was performed by different operators. One prescribed 3D ultrasound control in case of difficulties with the installation; other indications where systematics.

RESULTS

The Essure^®'s position is right in 79% of cases. Twenty-eight implants appear incorrectly positioned on ultrasound 3D positioning. Abnormalities found are those described by the classification proposed in the literature. In one case, the curvature of the implant, not taking into account this classification, allowed to evoke a tubal perforation. Among the 28 cases of non-visualized implants in place, 3 cases of wrong position of the implant were confirmed by additional examinations (laparoscopy or HSG). For 14 cases, the ASP or HSG disproved the wrong position of the implants. In other cases, we did not have other complementary examinations.

CONCLUSION

Ultrasonography 3D seems to be the method of choice to control implants for simple implementation and good reproducibility. However, the interpretation of 3D ultrasound images is sometimes difficult. The study of the curvature of the implant should be systematically analyzed not to miss a tubal perforation.

Essure Microinsert Abdominal Migration after Hysteroscopic Tubal Sterilization of an Appropriately Placed Essure Device: Dual Case Reports and Review of the Literature

Background. The Essure device is a method of permanent sterilization widely used in the US that has proven to be safe and effective in most cases. However, there have been reports of device migration that have led to failed tubal occlusion as well as several other serious complications resulting from the presence of the device in the abdominal cavity. Case. This paper represents two cases of failed tubal occlusion by an appropriately placed Essure device without signs or symptoms of further complications related to device migration. Conclusion. Although there have only been 13 reported cases of abdominal device migration since November 2014, this case indicates that the actual number may be higher than reported since it is possible for migration to occur without additional complications. In the majority of reported cases of abdominal migration a major complication requiring surgical correction occurred, such as adhesions, small bowel obstruction, bowel perforation, or persistent pelvic pain. To avoid these complications it is recommended that migrating implants be removed; however, this case also represents an example of when a migrating device may remain in situ in an asymptomatic patient.