What are the Factors Predictive of Hysterosalpingogram Compliance After Female Sterilization by the Essure Procedure in a Publicly Insured Population?

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.).

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.

Improving Rates of Post-Essure Hysterosalpingography in an Urban Population Using Electronic Tracking Reminders

STUDY OBJECTIVE

To demonstrate the efficacy of electronic reminders for follow-up hysterosalpingography (HSG) after Essure hysteroscopic sterilization in an urban tertiary care hospital obstetrics and gynecology practice.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-3).

SETTING

Obstetrics and gynecology practice at a university-affiliated urban tertiary care teaching hospital.

PATIENTS

Two hundred and fifty patients who underwent Essure hysteroscopic sterilization between June 2011 and July 2014.

INTERVENTION

Implementation of electronic reminders for the office staff.

MEASUREMENTS AND MAIN RESULTS

Two hundred and fifty of 259 patients (96.5%) underwent Essure hysteroscopic sterilization and successful placement of coils into bilateral Fallopian tubes. Among these 250 patients, 135 (54%) returned for HSG at 3 months post-Essure as advised at the time of procedure. The use of electronic reminders prompted another 45 patients (18%) to return for HSG, improving the total post-Essure follow-up rate to 72%.

CONCLUSION

Electronic reminders for the office staff of an urban tertiary care hospital's obstetrics and gynecology practice is an effective method for improving the rate of post-Essure HSG.

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).

Improving adherence to hysterosalpingography after hysteroscopic sterilization using an electronic reminder

STUDY OBJECTIVE

The US package labeling of the Essure system (Bayer Healthcare, Whippany, NJ) requires hysterosalpingography (HSG) as a confirmatory test after hysteroscopic sterilization to ensure proper placement and tubal occlusion. Previous studies have shown that implementation of a protocol to track patients after Essure procedures can improve HSG adherence. The primary objective of this study was to investigate whether implementation of an electronic reminder for the office staff increases post-Essure HSG adherence.

DESIGN

Retrospective cohort study of patients who underwent the Essure procedure between January 2005 and January 2012 (Canadian Task Force classification II-3).

SETTING

University-affiliated hospital.

PATIENTS

Two hundred eleven patients underwent the Essure procedure during the study period.

INTERVENTIONS

Implementation of an electronic reminder for the office staff.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-seven (64.9%) patients underwent the procedure before implementation of the electronic reminder, and 74 (35.1%) patients underwent the procedure after implementation. Although the odds of post-Essure HSG adherence increased in the overall (odds ratio [OR] = 1.7; 95% confidence interval [CI], .9-3.2) and faculty practice (OR = 2.1; 95% CI, .2-18.6) patient population, these results were not statistically significant. In contrast, the odds of post-Essure HSG adherence increased by almost 3-fold (OR = 2.9; 95% CI, 1.4-6.3) in the resident clinic patient population (p = .003).

CONCLUSION

Implementation of an electronic reminder increases post-Essure HSG adherence in the resident clinic patient population.

Adherence to hysterosalpingogram appointments following hysteroscopic sterilization among low-income women

BACKGROUND

The few studies on post-Essure hysterosalpingogram (HSG) adherence rates show inconsistent results. This study examined associations between sociodemographic variables not examined in prior studies and HSG adherence among low-income women.

STUDY DESIGN

Medical records of 286 women who underwent sterilization between August 31, 2005, and September 30, 2011, were reviewed. chi-Square and Mann-Whitney U tests were used to determine variable associations with HSG adherence.

RESULTS

The adherence rate for the first HSG was 85.0% (243/286). Variables associated with adherence were lower education level (p=.01), not working outside the home (p=.04), being married (p<.0001), lower gravidity (p=.03), fewer lifetime number of sexual partners (p<.0001), no sexually transmitted infection history (p<.01), Hispanic ethnicity (p<.0001), Spanish as a primary language (p<.0001) and living farther from the clinic (p<.01).

CONCLUSIONS

This study demonstrates that achieving high rates of adherence with the recommended HSG following Essure placement is feasible among low income populations. Furthermore, not speaking English or having to commute a far distance to the clinic do not appear to be barriers. This is encouraging considering the importance of this test to confirm tubal occlusion.