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

Association of Hysteroscopic vs Laparoscopic Sterilization With Procedural, Gynecological, and Medical Outcomes

IMPORTANCE

Safety of hysteroscopic sterilization has been recently questioned following reports of general symptoms such as allergy, tiredness, and depression in addition to associated gynecological results such as pelvic pain, perforation of fallopian tubes or uterus, and unwanted pregnancy.

OBJECTIVE

To compare the risk of reported adverse events between hysteroscopic and laparoscopic sterilization.

DESIGN, SETTING, AND PARTICIPANTS

French nationwide cohort study using the national hospital discharge database linked to the health insurance claims database. Women aged 30 to 54 years receiving a first hysteroscopic or laparoscopic sterilization between 2010 and 2014 were included and were followed up through December 2015.

EXPOSURES

Hysteroscopic sterilization vs laparoscopic sterilization.

MAIN OUTCOMES AND MEASURES

Risks of procedural complications (surgical and medical) and of gynecological (sterilization failure that includes salpingectomy, second sterilization procedure, or pregnancy; pregnancy; reoperation) and medical outcomes (all types of allergy; autoimmune diseases; thyroid disorder; use of analgesics, antimigraines, antidepressants, benzodiazepines; outpatient visits; sickness absence; suicide attempts; death) that occurred within 1 and 3 years after sterilization were compared using inverse probability of treatment-weighted Cox models.

RESULTS

Of the 105 357 women included (95.5% of eligible participants; mean age, 41.3 years [SD, 3.7 years]), 71 303 (67.7% ) underwent hysteroscopic sterilization, and 34 054 (32.3%) underwent laparoscopic sterilization. During the hospitalization for sterilization, risk of surgical complications for hysteroscopic sterilization was lower: 0.13% for hysteroscopic sterilization vs 0.78% for laparoscopic sterilization (adjusted risk difference [RD], -0.64; 95% CI, -0.67 to -0.60) and was lower for medical complications: 0.06% vs 0.11% (adjusted RD, -0.05; 95% CI, -0.08 to -0.01). During the first year after sterilization, 4.83% of women who underwent hysteroscopic sterilization had a higher risk of sterilization failure than the 0.69% who underwent laparoscopic sterilization (adjusted hazard ratio [HR], 7.11; 95% CI, 5.92 to 8.54; adjusted RD, 4.23 per 100 person-years; 95% CI, 3.40 to 5.22). Additionally, 5.65% of women who underwent hysteroscopic sterilization required gynecological reoperation vs 1.76% of women who underwent laparoscopic sterilization (adjusted HR, 3.26; 95% CI, 2.90 to 3.67; adjusted RD, 4.63 per 100 person-years; 95% CI, 3.38 to 4.75); these differences persisted after 3 years, although attenuated. Hysteroscopic sterilization was associated with a lower risk of pregnancy within the first year of the procedure but was not significantly associated with a difference in risk of pregnancy by the third year (adjusted HR, 1.04; 95% CI, 0.83-1.30; adjusted RD, 0.01 per 100 person-years; 95% CI, -0.04 to 0.07). Risks of medical outcomes were not significantly increased with hysteroscopic sterilization compared with laparoscopic sterilization.

CONCLUSIONS AND RELEVANCE

Among women undergoing first sterilization, the use of hysteroscopic sterilization was significantly associated with higher risk of gynecological complications over 1 year and over 3 years than was laparoscopic sterilization. Risk of medical outcomes was not significantly increased over 1 year or over 3 years. These findings do not support increased medical risks associated with hysteroscopic sterilization.

Minimally Invasive Gynecologic Surgery for Benign Conditions: Progress and Challenges

OBJECTIVE

The objective of this review is to evaluate the progress made in laparoscopic and hysteroscopic gynecologic surgery and address challenges still faced by surgeons using minimally invasive techniques to improve the care of women with noncancerous gynecologic problems.

METHODS

Relevant literature was reviewed and evidence-based arguments put forward in the article for the progress that has been made and the deficiencies that still exist.

RESULTS

In the last 2 decades, enormous progress has been made in providing minimally invasive surgical options for women with gynecologic diseases. The progress has been especially striking in the performance of hysterectomy, the most common major surgery performed on nonpregnant women. The recent controversy over power morcellation has revealed a poor understanding of the literature concerning leiomyosarcoma leading to confusion and consequently denial of minimally invasive surgical options for many women. Hysteroscopic surgery has been evolving rapidly with the development of hysteroscopic morcellator, global endometrial ablation systems, and hysteroscopic tubal sterilization.

CONCLUSIONS

Although huge advances have been made in minimally invasive gynecologic surgery, high-quality evidence from well-designed clinical trials is lacking for many of the new technologies. Accurate estimates regarding the risk of occult leiomyosarcoma are also lacking. Additional research is urgently needed to address these deficiencies.

Confirmation Testing of Essure Microinserts in Unintended Pregnancies Using a 10-Year Retrospective Database

STUDY OBJECTIVES

To examine the imaging modality used in cases of Essure failures and determine the cause of the unintended pregnancies (noncompliance to follow-up recommendations, misinterpretation of the imaging test, or device failure).

DESIGN

Retrospective, single-center interventional cohort (Canadian Task Force classification II-2).

SETTING

Tertiary level hospital.

PATIENTS

Women who have had Essure placement and subsequent pregnancy.

INTERVENTIONS

Coding data from the Regina General Hospital was examined for any pregnancy occurring after an Essure procedure. The hospital charts were then reviewed for data collection. A separate imaging database established over the same time frame was then reviewed to determine the imaging modality used in each case (transvaginal ultrasound [TVU], hysterosalpingogram [HSG], or none). Results of the imaging study were reviewed and the cause of the failure determined.

MEASUREMENTS AND MAIN RESULTS

Twenty-four pregnancies in 25 women were identified after Essure procedures from January 1, 2003 to March 31, 2013. There were 4 in vitro fertilization pregnancies and 4 pregnancies where the woman had been instructed not to rely on the devices because of incomplete placement noted at time of the procedure. Therefore, 17 unintended pregnancies occurred of a total 2080 procedures performed. Examination of the imaging studies revealed that 11 were due to patient noncompliance (either early cessation of backup contraception or failure to go for confirmatory imaging), 5 due to misinterpretation of the imaging tests (3 HSG, 2 TVU), and 1 device failure. This reveals a cumulative failure rate of 6 of 2080 or .29% over 10 years with only .04% (1/2080) being device related.

CONCLUSION

Essure sterilization is an effective means of permanent contraception with a device failure rate of only .04%. Most unintended pregnancies after the Essure procedure result from a failure to comply with follow-up recommendations, and strategies to improve compliance should be emphasized.

Pregnancy following hysteroscopic sterilization at an Urban Abortion Clinic- A case series: Are We looking in the wrong places?

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.

A Meta-Analysis of Bilateral Essure® Procedural Placement Success Rates on First Attempt

Background: The Essure® (Bayer HealthCare Pharmaceuticals, Leverkusen, Germany) female sterilization procedure entails using a hysteroscope to guide a microinsert into the Fallopian tube openings. Failed placement can lead to patient dissatisfaction, repeat procedures, unintended or ectopic pregnancy, perforation of internal organs, or need for subsequent medical interventions. Additional interventions increase women's health risks, and costs for patients and the health care industry. Demonstrated successful placement rates are 63%-100%. To date, there have not been any systematic analyses of variables associated with placement rates. Objectives: The aims of this review were: (1) to estimate the average rate of successful bilateral Essure microinsert placement on first attempt; and (2) to identify variables associated with successful placement. Materials and Methods: A meta-analysis was conducted on 64 published studies and 19 variables. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, all published studies between November 2001 and February 2015 were reviewed. The studies were taken from from PubMed and Google Scholar, and by using the the "snowball" method that reported variables associated with successful bilateral Essure placement rates. Results: The weighted average rate of successful bilateral microinsert placement on first attempt was 92% (0.92 [95% confidence interval: 0.904-0.931]). Variables associated with successful placements were: (1) newer device models; (2) higher body mass index; and (3) a higher percent of patients who received local anesthesia. Conclusions: The data gathered for this review indicate that the highest bilateral success rates may be obtained by utilizing the newest Essure device model with local anesthesia in heavier patients. More standardized data reporting in published Essure studies is recommended. (J GYNECOL SURG 31:308).