Quality of life after laparoscopic removal of Essure® sterilization devices

Plasma and peritoneal fluid cytokine profiles in patient with Essure® implant: Towards a molecular signature?

OBJECTIVE(S)

Many patients with Essure® implant may experience adverse events related to the device. Although local inflammation does not appear to be the pathophysiological mechanism underlying the symptoms, systemic inflammation could play a role. In the present study, as cytokines are involved in the inflammatory process, we proposed to investigate the profile of circulating and peritoneal cytokines.

STUDY DESIGN

In this retrospective study, we evaluated the levels of cytokines in peritoneal fluid (PF) as well as in plasma sample from three different groups: Essure® group, endometriosis group (known to be associated with immune dysregulation), and control group.

RESULTS

There were 60 symptomatic patients with Essure® device, 30 patients with endometriosis and a control group of 30 patients. The PF levels of Interleukin-10 (IL-10), Interleukin-6 (IL-6), and Monocyte chemoattractant protein-1 (MCP-1) were statistically higher in endometriosis group than in Essure® group and control group. The plasma level of MCP-1 was higher in Essure® group than in endometriosis group and control group. The plasma level of TNF-α was higher in Essure® group than in control group.

CONCLUSIONS

The chemokine MCP-1 as well as the pro-inflammatory TNF-α, are known to be increased in patients with fibromyalgia and chronic fatigue syndrome. Since patients with Essure® may exhibit symptoms similar to fibromyalgia, MCP-1 and TNF-α may be relevant markers in symptomatic patients with Essure®. Because of the lack of longitudinal data (no evaluation of postoperative cytokine profile and no assessment of the level of clinical improvement), other studies are needed to confirm these preliminary results.

Clinical and histopathological correlations in symptomatic patients with salpingectomy for Essure® implant removal: a cross-sectional study

PURPOSE

Many concerns have been raised about adverse effects related to Essure® device. Several pathophysiological hypotheses have been proposed including allergic reactions, Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants, galvanic corrosion with release of heavy metals and inflammation. In the present study, we aimed to focus on inflammation process by performing a histopathological evaluation of Fallopian tubes in symptomatic patients with Essure® removal.

MATERIALS AND METHODS

A cross-sectional study with identification of the type of inflammatory response and characterisation of inflammatory cells in the surrounding tubal tissue around the Essure® (STTE) and at distance from the implant. Histopathological and clinical correlations were also investigated.

RESULTS

In the STTE from 47 cases, acute inflammation was observed in 3/47 (6.4%) cases. Chronic inflammation with lymphocytes (42.5%, 20/47) was associated with a significant higher pre-operative pain score (p = .03). Fibrosis was noted in 43/47 (91.5%) cases. Fibrosis without lymphocytes (51.1%, 24/47) was statistically associated with significant reduced pain (p = .04). At distance from the Essure® implant, only chronic inflammation with lymphocytes was present in 10/47 (21.7%) cases.

CONCLUSIONS

Inflammation response do not seem to be enough to explain all the Essure-related adverse outcomes, suggesting the involvement of other biological mechanisms.

CLINICALTRIALS.GOV IDENTIFIER

NCT03281564.

Clinical improvement after Essure® devices removal: a systematic review

PURPOSE

Essure® implant is a permanently implanted minimally invasive birth control device for women (female sterilisation) widely used between 2002 and 2018. Many adverse events were reported by patients. Increasingly removal procedures have been performed in symptomatic patients. However, there is a lack of in-depth studies on clinical improvement after Essure® removal. We aimed to review all clinical studies about symptoms and quality of life (QoL) after removal procedures.

MATERIALS AND METHODS

A review of literature in electronic search in Medline and Embase databases from January 2002 to January 2022 using the following keywords: Essure; Essure removal; quality of life; symptomatology improvement.

RESULTS

Out of 764 articles in the initial database, 18 clinical studies were eligible for inclusion in our literature review. Overall clinical improvement rates after removal ranged from 21% to 98%. All symptoms were less frequent after Essure® removal, although with large discrepancies between studies. Lack of improvement was reported between 1% to 15% of patients. Rate of patients with improvement of QoL after removal ranged from 58 to 98%. The pain was reported as significantly reduced after the surgery.

CONCLUSIONS

In the available literature, Essure® removal in symptomatic patients may improve symptoms and quality of life. This should be discussed in the benefits and risks ratio before deciding on the best option of management.

Laparoscopic removal of Essure device techniques, perioperative findings and evaluation of patient's satisfaction: A case series

OBJECTIVE

To evaluate perioperative outcomes and symptom resolution in women undergoing Essure removal.

METHODS

Single centre cohort study at a large University Teaching Hospital in the UK. Symptoms and Quality of life (QoL) were assessed using a standardised questionnaire administered at 6-months and up to 10-years following removal of Essure® devices.

RESULTS

61 women underwent surgical removal of Essure® devices representing 61/1087 (5.6%) of all women undergoing this hysteroscopic form of sterilization. Patients who had Essure® removal were more likely to have a previous caesarean section [38% vs 18%; OR 0.4, 95% CI 0.2-0.6; P <0.001]. The main indication for removal was pelvic pain (49/61, 80%). Removal was achieved by laparoscopic bilateral salpingectomy/cornuectomy (44/61,71%) or hysterectomy (17/61, 28%). At surgery, perforated device was seen in 4/61 (7%) cases. 26/61 (43%) of patients had concomitant pelvic pathology; 12/26 (46%) had fibrous adhesions, 8/26 (31%) endometriosis, 4/26 (15%) adenomyosis, and 2/26 (8%) had endometriosis and adenomyosis. 10 patients underwent further procedure following removal for ongoing symptoms. 55/61 women (90%) responded to the post removal symptom questionnaire. Most respondents to the quality of life survey 42/55 (76%) reported total or some improvement. 42/53 (79%) had total or some improvement in pelvic pain, 9/13 (69%) in mental health and 10/12 (83%) in bleeding.

CONCLUSION

Surgical removal of Essure® devices appears to improve symptoms thought to be attributable to the presence of these uterine implants in most women. However, patients should be counselled that one in five women may experience persistent or even worsening symptoms.

Long-term quality of life after surgical Essure removal for device-attributed symptoms

OBJECTIVE

To analyze quality of life(QoL) and symptom resolution after surgical removal of Essure devices.

METHODS

Single-center cohort study which included patients with Essure removal between February 2017 and March 2018. Surgery was performed in 65 patients by laparoscopy (Salpingectomy only or Hysterectomy). Questionnaires were used to assess QoL(SF-36), emotional disorders(HAD) and symptoms preoperatively, at 3 months and 4 years postoperatively.

RESULTS

4(6,1%) and 16(24,6%) patients were lost of follow-up at three months and 4 years postoperatively respectively. Four(6,1%) intraoperative surgical complications occurred. During the three-months postoperative period, 3(4,6%) complications occurred: five Clavien Dindo Grade 1 complications (umbilical hematoma) and one Grade 2 complication (hyperthermia and digestive disorder requiring antibiotic therapy). Preoperative QoL scores were lower than those of general population. Scores were significantly improved at 3 months and 4 years postoperatively. At 4 years postoperatively, 17/49(34,7%) had a complete regression of symptoms, 21/49(42,8%) partial resolution and 11/49(22,4%) no improvement. 27/49(55,1%) patients made the connection between symptoms and ESSURE device after media coverage. 22/49(44,89 %) were influenced by media coverage in their decision of surgery. There was a higher percentage of patients with anxiety disorder before Essure removal than 4 years after [22/44 (50 %) versus 11/44 (25 %); p = 0.0045].

CONCLUSION

Essure removal has a restorative role in terms of QoL in short and long-term. Patients should be informed about possibility of no improvement after surgery and surgical morbidity. Larger prospective cohort is needed to make a well-considered decision about risks of surgery compared with expected benefits.

Release of metal elements from the Essure implant: A prospective cohort study

OBJECTIVE(S)

The causal mechanistic relationships between Essure® and adverse effects are unclear, but corrosion in the in-vivo environment with release of metal ions may be suspected. Here we evaluated the concentrations of nickel (Ni), chromium (Cr) and tin (Sn) in the peritoneal fluid (PF) and in the fallopian tube (FT) during laparoscopic Essure® removal compared to a control group.

STUDY DESIGN

Ni, Cr and Sn concentrations were determined in the PF and FT from two groups(group A: symptomatic patients with Essure®) vs group B (control group without Essure®) by Inductively Coupled Plasma Mass Spectrometry analysis. Correlation between metal elements concentrations and reported pre-operative symptoms was also investigated.

RESULTS

There were 131 patients in group A vs 92 control patients in group B. The concentrations of Cr and Ni in PF between both groups were significantly different (p < 0.0001) while there was no statistical difference for Sn (p = 0.58). There was also a significantly higher concentration in the FT for the 3 metal elements in group A than in group B (p < 0.0001). There were differential dynamics of the levels of metal elements based on the length of time between the placement and removal of Essure®.

CONCLUSIONS

There was a chronic exposure to metal elements in symptomatic patients with Essure® raising the question of the relationship between adverse effects and these potential toxic metals.

Could the anatomic location of Essure® device explain the impairment of quality of life?

BACKGROUND

Since health-related quality of life (HRQL) could improve after removal of Essure^® (Bayer, Leverkusen, Germany) inserts in symptomatic patients, we aimed to assess whether such postoperative enhancement was linked to the anatomic placement of the device.

METHODS

Correct and incorrect placed Essure^® (Bayer) were identified in the electronic database of the French cohort Ablimco (cohort of consenting patients with laparoscopic Essure^® [Bayer] removal). HRQL, pain and heavy menstrual bleeding were evaluated after Essure^® (Bayer) removal with validated quality of life questionnaires (Short Form12 Questionnaire, Visual Analogue Scale, French version of the McGill Pain Questionnaire and the pictorial blood assessment chart PBAC).

RESULTS

Sixty-five patients were included in the study divided in two groups (group A with correct placement: 45 patients and group B with incorrect placement: 20 patients). HRQL and Pain Index were improved in both groups at 6 months post-surgery. There was not any statistically significant difference between group A and B. The PBAC score increased at 6 months postoperatively in group A and B without any statistically significant difference between them.

CONCLUSIONS

Postoperative improvement of quality of life and pain index was similar whatever the position of the implant. This suggests that symptomatology and quality of life are not related to the anatomic location of the Essure^® (Bayer) implants.

Confirmation of the systematic presence of tin particles in fallopian tubes or uterine horns of Essure implant explanted patients: A study of 18 cases with the same pathological process

OBJECTIVE

To examine associations between local and systemic symptoms and the wear of the tin weld of Essure implants.

DESIGN

study of a series of cases.

SETTINGS

Two French hospitals.

PARTICIPANTS

Eighteen patients explanted by hysterectomy and salpingectomy for removal of their Essure implants between September 2019 and July 2020, have had a common anatomopathological process.

MAIN OUTCOME MEASURES

anatomopathological examination by optical microscopy and mineralogical analysis of the fallopian tube or uterine horn with scanning electron microscopy coupled with energy dispersive X-ray (SEM-EDX). Evaluation of local and systemic symptoms with a questionnaire. Examination of blood metal assays (nickel, chromium, and tin).

RESULTS

anatomopathological examination highlights foreign body granulomas, fibrosis, adenomyosis, nonspecific inflammation, cysts and myomas in the Fallopian tubes, uterine horns, or both and mentions the presence of foreign bodies in seven cases. SEM-EDX analyses showed, systematically, the presence of tin particles integrated in the wall near the weld, generally in clusters, and with a size ranging from about one micron to several dozen microns. The questionnaire shows that the most frequent local symptoms were pelvic pain, urinary disorders, bleeding, and pains during intercourse. The most common systemic symptoms were: asthenia, visual disturbances, amnesia, giddiness, dorsal pains, headaches, and joint pains. The majority of local and systemic symptoms decreased after explantation, but sometimes incompletely. Before explantation, high levels of nickel, tin and chromium were observed in 11/17, 1/7 and 2/17 patients. After explantation, tin levels were high in 3/11 patients.

CONCLUSIONS

our new anatomopathological process systematically demonstrates the presence of tin particles in tissue near the weld. These particles could be responsible for granulomatous inflammations as well as local symptoms. Many of the systemic symptoms are consistent with chronic organotin poisoning but further studies are needed to find out whether tin from the solder can be converted to organotin in the patients' bodies.

Outcomes after a Uterine-Sparing Approach to Essure Contraceptive Device Removal

BACKGROUND AND OBJECTIVE

To analyze long-term effectiveness of a conservative, uterine-sparing approach to laparoscopic Essure removal. Specific outcomes of interest include patient satisfaction, symptom resolution, and subsequent surgical intervention.

METHODS

A retrospective case series and follow-up survey. Patients who underwent laparoscopic Essure removal without concomitant hysterectomy between January 1, 2016 and December 31, 2019 were identified. Greater than 18 months after removal participants completed a survey assessing outcomes.

RESULTS

Twenty-nine patients underwent conservative Essure removal and there were 19 survey respondents. Among survey respondents, the mean length of time from Essure placement to removal was 56.7 months (range 5 - 117), and the mean length of time from removal to survey administration was 48.3 months (range 23 - 63). The most frequently reported symptoms were pain (100%), bleeding (52.6%), headache (42.1%), and dyspareunia (42.1%). Methods for removal included laparoscopic salpingectomy (58.6%), a combined hysteroscopic and laparoscopic approach (34.4%), and cornuectomy (6.9%). Regarding symptom improvement after Essure removal, 47.4% of patients reported total improvement, 36.8% reported almost total improvement, 5.3% reported some improvement, and 10.5% reported no improvement. Most patients (89.5%) reported satisfaction with their surgical results, and only two patients required subsequent surgical intervention for symptom management.

CONCLUSIONS

Most patients in our cohort reported total or almost total improvement in symptoms almost two years after Essure removal, with low rates of reintervention. A uterine-sparing approach to Essure removal, using laparoscopic and hysteroscopic modalities, may be a feasible and effective approach to addressing Essure-attributed symptoms.

ASIA (Shoenfeld's syndrome) due to hysteroscopic Essure sterilization

Essure (TM, Bayer; Leverkusen, Germany) may act as a potential cause of autoimmune/inflammatory syndrome by adjuvants (ASIA). Essure is a device hysteroscopically inserted into the fallopian tubes to elicit a local inflammatory response for permanent sterilization. Patients with ASIA present with a constellation of symptoms including fatigue, cognitive impairment, and arthralgias. It is well known that ASIA is triggered by implantation of foreign material such as breast implants and mesh for hernia repair. In the current study, we present a retrospective cohort of 33 patients electing to remove Essure due to pelvic pain and systemic symptoms consistent with an ASIA diagnosis, and detail a case report of an Essure patient. Furthermore, we reviewed the existing literature on adverse events associated with Essure and studies assessing outcomes following explantation. The concept that Essure may trigger ASIA is further supported by both in vivo and in vitro studies demonstrating immunostimulatory effects of the material components of the device. We conclude that the existing evidence is sufficient to recommend screening of Essure recipients for ASIA symptoms, and where indicated, discussion of the risks and potential benefits of surgical removal.

Surgical techniques for the removal of Essure® microinserts: a literature review on current practice

PURPOSE

To evaluate the different techniques for Essure^® microinserts removal and to assess the risk of fracture of the device and the intra- and post-operative complications in relation to surgical technique variants.

METHODS

Electronic search in Medline, Scopus and Embase databases using the following keywords: Essure; Essure removal; Essure surgical technique.

RESULTS

Out of 95 articles in the initial database, 17 studies were eligible for inclusion in our literature review. Several surgical techniques have been described in which the most frequent were laparoscopic salpingectomy (LS), laparoscopic cornuectomy (LC), laparoscopic or vaginal hysterectomy (LH, VH) with en-bloc salpingectomy. There were more fractures of the device with the LS procedure (6.25%) followed by the LC technique (2.77%), while there was no fracture with hysterectomy. However, peri-and post-operative complications were more severe and frequent with hysterectomy in comparison with the LC and LS procedures (respectively 8.1% Clavien Dindo grade 3 for the hysterectomy group, 1.11% for the LC procedure and 0.69% for the LS technique).

CONCLUSION

Due to the lack of standardised surgical treatment guidelines, a system of care networks for symptomatic patients with adverse effects related to Essure^® headed by specialised centres may offer a suitable and high-quality management with the appropriate removal techniques within two objectives: limiting the risk of fracture (with an en-bloc removal of the Essure^® microinserts) and avoiding intra- and post-operative complications.

Essure® removal in 10 steps

Many women request Essure^® removal because of possible side effects related to the device itself. Laparoscopic Essure^® removal in symptomatic women may be associated with improvement in quality of life. We aim to describe the surgical technique in ten steps in the accompanying video as the standardization of the laparoscopic Essure^® removal procedure could help to diminish the risk of fractures of the device with this easy and safe 10-step procedure.

Patients' satisfaction following laparoscopic cornuectomy for removal of hysteroscopic sterilization devices

OBJECTIVES

To evaluate patients' satisfaction and evolution of pre-operative symptoms at 6 months following laparoscopic cornuectomy for hysteroscopic sterilization implants removal.

MATERIAL AND METHODS

Retrospective study including all patients undergoing laparoscopic cornuectomy for implants removal in a tertiary care setting from January 2017 to October 2018. All women suffered from persistent and treatment-resistant gynecologic and non-gynecologic complaints since sterilization procedure. Patents' satisfaction was evaluated with the PGI-I questionnaire at 2 and 6 months following surgery.

RESULTS

Overall, 104 patients were enrolled. Main symptoms comprised asthenia (n = 80), chronic pelvic pain (n = 80), arthralgia (n = 70), abnormal uterine bleeding (n = 42) and headache (n = 40). Cornuectomy was feasible in all cases and led to complete devices removal in 101 women. Mean length of stay was 1.8 days, while outpatient management was feasible in 45.2 % of cases. One grade 3 complication occurred along the study period (hemoperitoneum requiring reoperation). Surgery was associated with a significant decrease in symptom occurrence, except for alopecia and weight loss. Patients' satisfaction was high: 91 % at 2 months and 97.6 % at 6 months reported an improvement in their health status compared to baseline situation. Satisfaction regarding each symptom was consistent with overall assessment, with most patients reporting significant improvement at both 2 and 6 months.

CONCLUSION

Laparoscopic cornuectomy is feasible and associated with high mid-term satisfaction in patients suffering from adverse effects attributed to hysteroscopic sterilization implants.