Hysteroscopic Sterilization Research Articles

Laparoscopic Resection of Ovarian Vessel Coils and a Tubal Occlusion Device

Video Objective To describe the anatomy of the ovarian vessels cephalad to the pelvic brim. Setting A 45 year old multiparous woman presents with chronic right pelvic pain following hysteroscopic tubal sterilization. Bilateral ovarian vein embolization was performed for suspected pelvic congestion syndrome. Her pain worsened post-embolization. After an extensive pelvic pain evaluation, the decision was made to remove her embolization and tubal occlusion coils. Interventions Laparoscopic dissection and removal of the right ovarian vessels above the pelvic brim is described. Multiple steps are required for a safe and complete resection: 1- Retroperitoneal access; 2- Maintaining hemostasis; 3- Traction/counter-traction; 4- sharp and blunt dissection; 5- judicious use of electrosurgical energy. Conclusion Successful dissection/resection of ovarian vessels is feasible and safe with in-depth knowledge of neighboring structures cephalad to the pelvic brim.

Tubal Re-Implantation Following Hysteroscopic Tubal Sterilization

Video Objective In this video, we demonstrate a novel laparoscopic technique of tubal re-implantation after hysteroscopic tubal sterilization with micro-inserts. Setting The patient is a thirty-eight-year-old gravida two para two who previously underwent Essure tubal occlusion. Although she understood the permanent and irreversible nature of Essure coils, she presented with desire of another pregnancy. She was well informed that in-vitro fertilization would offer her the best chance to get pregnant. However, due to personal reasons, she absolutely wanted tubal re-implantation. Interventions Laparoscopic bilateral cornuectomy, partial salpingectomy with removal of Essure coils and tubal re-implantation was performed. Postoperative management included oral antibiotics, removal of stents under hysteroscopy and hysterosalpingography. Conclusion This is the first reported case of tubal re-implantation following hysteroscopic tubal occlusion using the proposed method. The surgical steps and technical tips discussed are safe, and may help patients with desire of pregnancy following Essure insertion who seek alternative options to assisted reproductive technology.

Surgical Management for Removal of Essure Device

Video Objective To present two surgical cases of laparoscopic removal of Essure hysteroscopic sterilization device via salpingectomy with and without cornuectomy. Setting One 37-year-old woman with heavy menstrual bleeding, joint pain, and fatigue reported by rheumatology to have a nickel allergy who desired Essure removal and one 51-year-old woman with pelvic pain and multiple co-morbidities who desired Essure removal. Both patients underwent surgical management for the removal of Essure at an academic medical center. Interventions In this surgical video, we present two cases of women desiring Essure implant removal secondary to adverse effects from the device. The first case describes the step by step approach to removal of an intact Essure implant by laparoscopic salpingectomy. The second case describes an approach to removal of Essure by salpingectomy with cornuectomy which is particularly helpful when the endometrial cavity has been previously ablated as in second case, or if there was a complicated insertion with perforation. Additionally, we describe the Essure implant composition in detail, describing how intact removal is imperative as fracturing of the device may lead to further complications or adverse effects. Conclusion Laparoscopic salpingectomy with and without cornuectomy are safe and effective procedures for the intact removal of Essure and are feasible alternatives to hysterectomy for women who desire removal of Essure.

Are Adverse Events Attributed to Essure Associated With Nickel Sensitization?

Essure is an effective method for hysteroscopic sterilization. Reports of adverse effects, the underlying mechanisms of which are unknown, have increased in recent years. The aim of the study was to determine whether there is a relationship between adverse events attributed to Essure and nickel sensitization. Patients presenting alleged adverse reactions to Essure were referred for nickel patch testing before removal. Data regarding medical history of nickel sensitization and symptoms attributed to Essure were collected. Dimethylglyoxime spot tests were performed on the explanted Essure. There was a follow-up at 3 months to evaluate whether there is improvement of the symptoms after Essure removal. Nickel sensitization via the classic delayed hypersensitivity pathway did not seem to be responsible for adverse events attributed to Essure. Among systemic symptoms reported, extracutaneous symptoms had the highest prevalence. Systemic contact dermatitis to nickel could not be ruled out in one case.

Saline-Air-HyCoSy Is Equivalent to the Modified HSG Following Hysteroscopic Sterilization [11M

INTRODUCTION: Transvaginal ultrasound (TVU) is FDA approved for coil location (CL) only following hysteroscopic sterilization. We compared saline-air-hysterosalpingo-contrast-sonography (SA-HyCoSy) to modified HSG (mHSG) for confirmation of both CL and tubal occlusion (TO). METHODS: 19 women underwent SA-HyCoSy and mHSG after random assignment to one followed by the other. Percent agreement and predictive values of SA-HyCoSy for CL and TO compared to mHSG by two interpreters were calculated along with inter-rater reliability. Differences in procedural time and pain score using a Likert 11-point pain scale were recorded. RESULTS: In total, 38 fallopian tubes were evaluated. For each interpreter, satisfactory CL was noted with mHSG in 97.4% and 100% compared to satisfactory-optimal CL with TVU in 100% for a PPV of 97.4% and 100%, respectively. TO on mHSG was noted in 97.3% of tubes compared with SA-HyCoSy in 97.3% and 94.6% for a PPV of 100% and NPV of 50% and 33%, respectively. SA-HyCoSy agreed with mHSG for both interpreters in 97.4% and 95.7% (kappa=0.67, P<.01). SA-HyCoSy changed CL in 50% and 44.7% (P-NS), being down-graded 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) (P-NS) for each, respectively. Procedural time (7.5 vs 9.4 min) and pain scores (2.3 vs 3.1) were similar for mHSG and SA-HyCoSy. CONCLUSION: There is a high degree of accuracy for TO with SA-HyCoSy, though CL was changed in nearly half of cases. While procedural time and pain were higher, avoidance of radiation with SA-HyCoSy may outweigh any drawbacks.

Transcervical Migration of an Essure® Coil

Introduction: Essure® device malposition is a rare, but clinically significant complication, for which management is idiosyncratic. This case report describes an unusual example of Essure® migration in order to clarify reasonable management options. Case Presentation: A 50-year old G4 P2022 underwent hysteroscopic sterilization using the Essure® device. Insertion was complicated by fragmentation of both coils. Two years later, one of the coils was incidentally discovered protruding through the cervical os. The visible portion was clipped when attempts to remove the entire coil were unsuccessful. Conclusion: Difficult placement increases the risk of Essure® malposition. In asymptomatic patients, conservative management with removal of only a portion of the device is a rational approach.

Bilateral Essure Perforation into the Abdominal Cavity

The Essure implant is a Food and Drug Administration (FDA) - approved form of hysteroscopic sterilization. The device has been available since 2002 with over half a million placed in the United States. The safety and efficacy profile has been demonstrated in the literature and supported by the FDA. Here, we present a rare case of bilateral perforation into the abdominal cavity with one device ultimately let in-situ. Although Bayer, the manufacturer of Essure, plans to stop sale of the product by December 31, 2018 for financial reasons, providers may continue to have questions and concerns from implants placed previously.

Seven-Year Outcomes After Hysteroscopic and Laparoscopic Sterilizations.

To evaluate 7-year outcomes after hysteroscopic and laparoscopic sterilizations, including subsequent tubal interventions and hysterectomies. This observational cohort study included women undergoing hysteroscopic and laparoscopic sterilizations in outpatient and ambulatory surgical settings in New York State during 2005-2016. We examined subsequent procedures (tubal ligation or resection, and hysterectomy not related to uterine leiomyomas or gynecologic tumors) after the index procedures. After propensity score matching, we used Kaplan-Meier analysis to obtain estimated risks of subsequent procedures within 7 years of index sterilization procedures, and Cox proportional hazard models to compare the differences between groups. We identified 10,143 and 53,206 women who underwent interval hysteroscopic and laparoscopic sterilizations, respectively, in New York State during 2005-2016. The mean age of the cohort was 34.2 years (range 18-80). The propensity score-matched cohort consisted of 10,109 pairs of women. The estimated risk of undergoing an additional tubal ligation or resection within 7 years was higher after hysteroscopic sterilization than it was after laparoscopic sterilization (3.9% vs 1.6%, HR 2.89, 95% CI 2.33-3.57). The difference was most pronounced within the initial year after attempted sterilization (1.5% vs 0.2%; HR 6.39, 95% CI 4.16-9.80). There was no significant difference in the risk of receiving a hysterectomy (0.9% vs 1.2%; HR 0.73, 95% CI 0.53-1.00) between women who underwent hysteroscopic and laparoscopic sterilizations. Patients undergoing hysteroscopic sterilization have a higher risk of receiving an additional tubal resection or ligation than those undergoing laparoscopic sterilization, particularly within the first year of the index procedure. There is no difference in undergoing a subsequent hysterectomy between the two groups. With limited evidence of outcomes after hysteroscopic sterilization beyond 7 years and existing reports of removals years after initial implantations, continuous monitoring of long-term outcomes for women who received the device is warranted.

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

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). A prospective study (Canadian Task Force classification II-2). The department of obstetrics and gynecology in a teaching hospital. 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. 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. 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. 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.

Long-term Outcomes After Elective Sterilization Procedures—A Comparative Retrospective Cohort Study of Medicaid Patients

(Abstracted from Contraception 2018;97:428–433) The second most common form of contraception among reproductive-aged women in the United States is female sterilization, although trends suggest declining rates. Methods available for interval sterilization include laparoscopic tubal ligation (TL) and hysteroscopic sterilization (HS).

Comparison of Hysteroscopic Sterilization versus Traditional Bilateral Tubal Ligation and Concomitant Endometrial Ablation with the Development of Post Ablation Tubal Sterilization Syndrome (PATSS)

Comparison of Hysteroscopic Sterilization versus Traditional Bilateral Tubal Ligation and Concomitant Endometrial Ablation with the Development of Post Ablation Tubal Sterilization Syndrome (PATSS)

Outcomes of hysteroscopic sterilization in an urban academic medical center from 2003 to 2014

Objectives: Given limited data on hysteroscopic sterilization outcomes and controversy surrounding side effects, we evaluated outcomes and complications following hysteroscopic sterilization in an urban academic medical center from 2003 to 2014.

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

(Abstracted from JAMA 2018;319:375–387) The main types of female sterilization in developed countries are laparoscopic and hysteroscopic sterilization. Approximately 1 million women worldwide have undergone the hysteroscopic procedure.

Antibiotic Prophylaxis in Surgical Sterilization: Following the Recommendations [29G

INTRODUCTION: Surgical site infections are the most common surgical complication. Antibiotic administration perioperatively has been shown to reduce associated morbidity, however, indiscriminate use has been associated with adverse outcomes. Selective antibiotic prophylaxis guidelines have been published by the American College of Obstetricians and Gynecologists (ACOG) for gynecologic procedures. Little is known regarding adherence to these recommendations. The primary objective was to determine adherence to ACOG recommendations for antibiotic prophylaxis in surgical sterilization. The secondary objective was to evaluate the patterns and predictors of appropriate antibiotic prophylaxis. METHODS: A retrospective chart review of preoperative antibiotics for laparoscopic and hysteroscopic sterilization procedures was performed at a single institution, Banner University Medical Center - Phoenix (BUMCP), from 01/01/2014 to 12/31/2014. Descriptive data were analyzed using chi-squared for categorical variables and Student t-test for continuous variables. P-values &lt;.05 were considered significant. RESULTS: Of 165 women who met inclusion criteria, 50.9% received antibiotic prophylaxis outside of ACOG guidelines. Patient age, race and insurance status were not predictive of inappropriate prophylaxis. Women who underwent hysteroscopic sterilization were less likely to receive inappropriate prophylaxis compared to laparoscopic sterilization (18.6% vs 68.9%, P&lt;.001). Antibiotic administration was less likely in cases assisted by lower-level residents compared to cases assisted by upper-level residents (46.4% vs 69.4%, P=.02). The number of years of attending experience was not predictive of adherence. CONCLUSION: There is widespread misuse of perioperative antibiotics for surgical sterilizations. Increased education and quality improvement is needed within BUMCP (our institution) to align practice patterns with evidence based recommendations.

ACOG Technology Assessment No. 13 Summary: Hysteroscopy.

Hysteroscopy is performed to view and treat pathology within the uterine cavity and endocervix. Diagnostic hysteroscopy allows visualization of the endocervical canal, endometrial cavity, and fallopian tube ostia. Operative hysteroscopy incorporates the use of mechanical, electrosurgical, or laser instruments to treat intracavitary pathology and perform hysteroscopic sterilization procedures. Selection of a distending medium requires consideration of the advantages, disadvantages, and risks associated with various media as well as their compatibility with electrosurgical or laser energy. A preoperative consultation allows the patient and physician to discuss the hysteroscopic procedure, weigh its inherent risks and benefits, review the patient's medical history for any comorbid conditions, and exclude pregnancy. Known pregnancy, genital tract infections, and active herpetic infection are contraindications to hysteroscopy. The most common perioperative complications associated with operative hysteroscopy are hemorrhage, uterine perforation, and cervical laceration. The procedure is minimally invasive and can be used with a high degree of safety.

Pregnancy After Tubal Sterilization in a Woman Treated with Biologics for Severe Psoriasis.

Little is known about whether immunosuppressed patients mount the immunological response necessary to ensure tubal occlusion. Theoretical concern for non-occlusion has limited the use of hysteroscopic sterilization in patients on immunosuppressive therapies. The effects of tumor necrosis factor-alpha (TNF-α) blockers and interleukin (IL)-17 inhibitors on contraception and pregnancy for patients with psoriasis are poorly documented. We report a case of pregnancy that ended in miscarriage in a patient treated first with TNF-α and then with IL-17 inhibitors for severe psoriasis after tubal sterilization with micro-inserts. Our observation suggests that the efficacy of tubal sterilization by micro-inserts may be impaired by these two biologics and that the risk of miscarriage may be increased in women with psoriasis treated with secukinumab.

Obstetric Outcomes After Failed Hysteroscopic and Laparoscopic Sterilization Procedures.

To compare obstetric outcomes after failed hysteroscopic and laparoscopic sterilization. This retrospective cohort study examined pregnancy outcomes including live birth, preterm birth, stillbirth, spontaneous abortion, therapeutic abortion, ectopic pregnancies, and gestational trophoblastic disease using a commercial claims administrative database for the years 2007-2013. We used a Z-test to compare pregnancy outcomes per 100 person-years based on type of sterilization. Cox proportional hazard models controlled for patient age, geographic region, urbanicity, comorbidities, and insurance type. We evaluated 997 pregnancy outcomes among 817 women from a total of 70,115 women with a history of either hysteroscopic sterilization (n=387 pregnancies/27,724 cases) or laparoscopic sterilization (n=610 pregnancies/42,391 cases). Women undergoing hysteroscopic sterilization were slightly older than, but otherwise similar to, women undergoing laparoscopic sterilization. The most common outcome was live birth, which was more likely after hysteroscopic sterilization compared with laparoscopic sterilization (adjusted hazard ratio 1.32, 95% CI 1.09-1.60). The rate of spontaneous abortion was not statistically significantly different between the two groups. Therapeutic abortion occurred more often after hysteroscopic sterilization (adjusted hazard ratio 1.49, 95% CI 1.10-2.01), whereas ectopic pregnancies occurred less often (adjusted hazard ratio 0.12, 95% CI 0.05-0.29) compared with laparoscopic sterilization. Hysteroscopic sterilization is associated with higher rates of live birth and lower rates of ectopic pregnancy compared with laparoscopic sterilization. Spontaneous abortion and preterm birth rates were similar in both groups. These data do not support an adverse effect of hysteroscopic sterilization on subsequent pregnancy outcomes.

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

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

Weighing the Options for Tubal Sterilization: Hysteroscopic or Laparoscopic?

To evaluate the outcomes of hysteroscopic versus laparoscopic tubal sterilization, investigators in France conducted an observational cohort study

Evaluating the Long-term Safety of Hysteroscopic Sterilization

Evaluating the Long-term Safety of Hysteroscopic Sterilization