Office hysteroscopic sterilization compared with laparoscopic sterilization: A critical cost analysis

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

Outpatient uterine assessment and treatment unit in patients with abnormal uterine bleeding: an economic modelling study

BACKGROUND

Most often in Canada, the evaluation and management of abnormal uterine bleeding occurs under general anesthesia in the operating room. We aimed to assess the potential cost-effectiveness of an outpatient uterine assessment and treatment unit (UATU) compared with the current standard of care when diagnosing and treating abnormal uterine bleeding in women.

METHODS

We performed a cost-effectiveness analysis and developed a probabilistic decision tree model to simulate the total costs and outcomes of women receiving outpatient UATU or usual care over a 1-year time horizon (Apr. 1, 2014, to Mar. 31, 2017) at a tertiary care hospital in Ontario, Canada. Probabilities, resource use and time to diagnosis and treatment were obtained from a retrospective chart review of 200 randomly selected women who presented with abnormal uterine bleeding. Results were expressed as overall cost and time savings per patient. Costs are reported in 2018 Canadian dollars.

RESULTS

Compared with usual care, care in the UATU was associated with a decrease in overall cost ($1332, 95% confidence interval [CI] -$1742 to -$1008) and a decrease in overall time to treatment (-75, 95% CI -89 to -63, d). The point at which the UATU would no longer be cost saving is if the additional cost to operate and maintain the UATU is greater than $1600 per patient.

INTERPRETATION

From the perspective of Canada's health care system, an outpatient UATU is more cost effective than usual care and saves time. Future studies should focus on the relative efficacy of a UATU and the total budget required to operate and maintain a UATU.

Results of the Insertion of Hysteroscopic Sterilization Devices in a Brazilian Public Hospital

OBJECTIVE

 To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility.

METHODS

 Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics.

RESULTS

 In 85.8% of the cases, the uterine cavity was normal, and the most commonly-described findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56 minutes (range: 1 to 10 minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%).

CONCLUSION

 Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

Hysteroscopic tubal occlusion using iso-amyl-2-cyanoacrylate in patients with hydrosalpinx

AIM

The aim of this work is to assess the effectiveness of hysteroscopic tubal occlusion using iso-amyl-2-cyanoacrylate, among infertile women with hydrosalpinx prior to in vitro fertilization (IVF).

METHODS

Hysteroscopic injection of fallopian tubes with hydrosalpinx by 0.5 mL iso-amyl-2-cyanoacrylate was done in 40 infertile women planning for IVF. The patients were then followed-up after 1 and 3 months, with hysterosalpingography (HSG) to confirm complete tubal occlusion. Reinjection with iso-amyl-2-cyanoacrylate was done in these patients with incomplete tubal occlusion after 1 month of the first injection, followed by HSG 2 months later to confirm complete tubal occlusion. Data were prescribed as range, mean and standard deviation (for parametric variables) and range, number and percentage (for categorical variables).

RESULTS

The total number of tubes injected in this study was 54, 42 (77.8%) of which were completely occluded after one injection while 12 (22.2%) were partially occluded. Reinjection of the partially occluded tubes was done, and (HSG) of all patients after 3 months of the primary injection confirmed 48 (88.9%) of the tubes completely occluded while 6 (11.1%) remained partially occluded. Thirty-two (80%) patients underwent one cycle of IVF/ET (embryo transfer), while 8 (20%) patients did not appear for follow-up. Among the patients who underwent IVF/ET, 24 (75%) got pregnant, while 8 (25%) failed to conceive. Among the pregnant patients, 8 (33.3%) delivered at term, 3 (12.5%) had first trimester abortion, while the remaining 13 (54.2%) did not deliver yet.

CONCLUSION

Iso-amyl-2-cyanoacrylate used for hysteroscopic tubal occlusion in patients with hydrosalpinx prior to IVF is safe and effective.

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.

Comparison of Healthcare Costs Among Commercially Insured Women in the United States Who Underwent Hysteroscopic Sterilization Versus Laparoscopic Bilateral Tubal Ligation Sterilization

BACKGROUND

This study evaluated healthcare costs of index procedures and during a 6-month follow-up of women who had hysteroscopic sterilization (HS) versus laparoscopic bilateral tubal ligation (LBTL).

MATERIALS AND METHODS

Women (18-49 years) with claims for HS and LBTL procedures were identified from the MarketScan commercial claims database (January 1, 2010, to December 31, 2012) and placed into separate cohorts. Demographics, characteristics, index procedure costs, and 6-month total healthcare costs and sterilization procedure-related costs were compared. Multivariable regression analyses were used to examine the impact of HS versus LBTL on costs.

RESULTS

Among the study population, 12,031 had HS (mean age: 37.0 years) and 7286 had LBTL (mean age: 35.8 years). The majority (80.9%) who had HS underwent the procedure in a physician's office setting. Fewer women who had HS versus LBTL received the procedure in an inpatient setting (0.5% vs. 2.1%), an ambulatory surgical center setting (5.0% vs. 23.8%), or a hospital outpatient setting (13.4% vs. 71.9%). Mean total cost for the index sterilization procedure was lower for HS than for LBTL ($3964 vs. $5163, p < 0.0001). During the 6-month follow-up, total medical and prescription costs for all causes ($7093 vs. $7568, p < 0.0001) and sterilization procedure-related costs ($4971 vs. $5407, p < 0.0001) were lower for women who had HS versus LBTL. Multivariable regression results confirmed that costs were lower for women who had HS versus LBTL.

CONCLUSIONS

Among commercially insured women in the United States, HS versus LBTL is associated with lower average costs for the index procedure and lower total healthcare and procedure-related costs during 6 months after the sterilization procedure.

Essure Surgical Removal and Subsequent Resolution of Chronic Pelvic Pain: A Case Report and Review of the Literature

Background. Hysteroscopic tubal sterilization (Essure) is a minimally invasive option for permanent contraception with high reported rates of patient satisfaction. A small percentage of these women subsequently choose to have the tubal inserts removed due to regret or perceived side effects such as late-onset pelvic pain secondary to placement of the Essure device. Case. A twenty-nine-year-old woman G4P4014 presented with a two-year complaint of chronic pelvic pain and dyspareunia after the hysteroscopic placement of an Essure device for sterilization. On reviewing the images of the HSG, it was noted that although tubal occlusion was confirmed, the left Essure coil appeared curved on itself in an elliptical fashion and did not seem to follow the expected anatomic trajectory of the fallopian tube. The patient reported resolution of chronic pelvic pain following laparoscopic removal of Essure device. Conclusion. A misplaced Essure device should be considered in the differential diagnosis of chronic pelvic pain in women who had difficult placement of the device. In addition to demonstrating tubal occlusion, careful examination of the configuration of the Essure microinserts on HSG examination provides valuable information in patients with pelvic pain after Essure placement.

Short-term surgical mission to the Dominican Republic: a cost-benefit analysis

OBJECTIVE

This study determines the cost-effectiveness of a recurring short-term surgical mission trip to the Dominican Republic.

BACKGROUND

The global burden of surgical disease is significant. Recent investigations have shown surgical treatment to be cost-effective at established hospitals within low- or middle-income countries (LMIC), drawing attention to surgical diseases world-wide. Another method of providing general surgical care in LMIC is short-term mission trips, but no studies have examined their cost-effectiveness.

METHODS

Consecutive week-long trips by the Midwest Medical Missions Michigan Chapter to the Dominican Republic were studied in 2010 and 2012. All costs were recorded, and operative logs were maintained. Costs of identical procedures carried out at the authors' host institution were estimated. Direct comparisons were made between the cost of surgeries performed in the USA and the estimated amount of money spent on the mission trips attributable to each procedure. Disability-adjusted life years (DALYs) averted were calculated for both trips.

RESULTS

The cost for all cases in 2010 would have been $255,187 if performed at the United States hospital and $398,177 in 2012. The amount actually spent on the trips was $61,924 in 2010 and $82,368 in 2012 - a relative cost-reduction of 79%. 473 DALYs were averted. An average of 6.9 DALYs were averted per patient, and the cost per DALY averted was $304.88.

CONCLUSIONS

The procedures on a surgical mission trip to the Dominican Republic were less expensive than similar care provided in the United States. The cost per DALY averted is low, demonstrating the cost-effectiveness of the trips.

Control and constraint for low-income women choosing outpatient sterilization

Little is known about Hispanics and their contraceptive choices in general, with some past studies detailing nonconsensual sterilization. This article is based on interviews with a mostly Hispanic sample of 44 women being sterilized at a public clinic in southeast Texas with the Essure device, which entails a new outpatient sterilization procedure. The women cited relationship factors, wanting to better their and their children's lives, and past reproductive histories as reasons for deciding on sterilization. They specifically chose Essure as a result of an apprehension of surgery and potential side effects from tubal ligation. Their choices, however, were limited by larger structural factors of work, family, the political economy, and the health care system. We concluded that this new sterilization technique provided more contraceptive choices for these women, yet more contraceptive decision-making autonomy and more equitable social structures are still needed.

Hysteroscopic placement of tubal sterilization implants: virtual reality simulator training

STUDY OBJECTIVE

To assess face and construct validity of a new virtual reality (VR) training simulator for hysteroscopic placement of tubal sterilization implants.

DESIGN

Nonrandomized, controlled trial comparing responses and performance of novices and experts on the simulator.

DESIGN CLASSIFICATION

Canadian task force II-1.

SETTING

Forty-six gynecologists were personally invited or recruited at the 33rd Conference of the French National College of Gynecologists and Obstetricians (CNGOF) from December 9 to 12, 2009, grouped as 20 experts and 26 novices. They all performed the defined sequence of virtual procedures on the simulator (case 1 for familiarization, case 4 for study assessment) and finally completed the study questionnaire.

MEASUREMENTS AND MAIN RESULTS

Responses to realism, educational potential, and general opinion were excellent, proving face validity. Significant differences between novices and experts were assessed for 7 of the 15 metrics analyzed, proving construct validity.

CONCLUSIONS

We established face and construct validity for EssureSim, an educational VR simulator for hysteroscopic tubal sterilization implant placement. The next steps are to investigate convergent and predictive validity to affirm the real capacity of transferring the skills learned on the training simulator to the patient in the operating room.

Tubal risk markers for failure to place transcervical sterilization coils

BACKGROUND

There is a growing body of literature on placement rates of the Essure® procedure, yet prior studies have not attempted to identify tubal-associated risk factors for placement failures. The current study examines risk markers associated with the inability to deploy the Essure® coils into the tubal lumen using the new ESS305 design.

STUDY DESIGN

We used electronic medical record data to assess risk markers associated with the inability to place the Essure coils in the tubal lumen using the new ESS305 design. A total of 310 attempted procedures between June 14, 2007, and April 29, 2011, were analyzed.

RESULTS

There were 18 tubal failures (5.8%) out of the 310 attempted procedures. A history of a prior sexually transmitted infection (STI) was associated with tubal failure (odds ratio 2.64, 95% confidence interval 1.01-6.90, p=.048).

CONCLUSIONS

We speculate that the observed association between a prior STI and an inability to place the coil was due to a past history of pelvic inflammatory disease.

[Ambulatory Essure implant placement sterilization procedure for women: prospective study comparing general anesthesia versus hypnosis combined with sedation]

OBJECTIVE

implant placement Essure, sterilization procedure for women, were performed under hypnosedation (HYP) and compared to the operative anxiety and analgesia of 12 patients operated-on under general anesthesia (GA).

STUDY DESIGN

prospective and comparative group study.

PATIENTS AND METHODS

two groups of twelve patients were matched and compared based on the choice of anesthetic technique: hypnotics (HYP) with possible additional sedation by propofol and remifentanil or GA involving propofol, sevoflurane and remifentanil. The assessment of anxiety and pain based on a visual analogy scale (0-10) and use of analgesics were studied in the recovery room and at discharge of hospital. The statistical analysis relies on nonparametric tests for paired data (Wilcoxon test).

RESULTS

all patients were operated. The two groups are statistically comparable. The preoperative anxiety before premedication is lower in the HYP group (p<0.05). No conversion to general anaesthesia is necessary in the HYP group, but five patients were using sedatives drugs but doses are very low compared to general anaesthesia. The analgesic consumption was equivalent in both groups.

CONCLUSION

we conclude that hypnosedation is a valuable alternative to traditional anesthetic techniques for ambulatory Essure implant. The use of hypnotic tool is an interesting alternative for the management of patients during invasive medical procedures or surgical, providing psychological benefits to the patient.

Vasectomy: the other (better) form of sterilization

Male sterilization (vasectomy) is the most effective form and only long-acting form of contraception available to men in the United States. Compared to female sterilization, it is more efficacious, more cost-effective, and has lower rates of complications. Despite these advantages, in the United States, vasectomy is utilized at less than half the rate of female sterilization. In addition, vasectomy is least utilized among black and Latino populations, groups with the highest rates of female sterilization. This review provides an overview of vasectomy use and techniques, and explores reasons for the disparity in vasectomy utilization in the United States.

Review of new office-based hysteroscopic procedures 2003-2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

A aplicação de adesivo de cianoacrilato por histeroscopia e os testes de perviedade na esterilização tubária de ovelhas

OBJETIVO: avaliar, por meio de testes de prenhez e de perviedade, a eficácia da obstrução tubária de ovelhas com adesivo de cianoacrilato aplicado por via histeroscópica. MÉTODO: 12 ovelhas adultas, com uma gestação anterior, foram distribuídas em três grupos: G-PO (n=3) submetidas à laqueadura tubária tipo Pomeroy; G-SH (n=3) aplicação de solução salina no istmo tubário por histeroscopia, e G-AD (n=6) aplicação de 0,5mL de n-butil-2-cianoacrilato no interior do istmo tubário, por histeroscopia. Depois de acasaladas por 90 dias com machos de comprovada fertilidade, as ovelhas não prenhas foram submetidas à laparotomia, retiradas as tubas uterinas, medidos os seus diâmetros e preparadas para testes de perviedade pela aplicação de azul de metileno e de pressão hidráulica (80mmHg). RESULTADOS: As ovelhas de G-PO e G-AD não ficaram prenhas (0%), em contraste com as SH (100%). O G-PO apresentou maior concentração de aderências (66,6%) e de granulomas (100%) em relação ao grupo AD (0%); o adesivo manteve-se íntegro no lúmen tubário. O diâmetro da tuba uterina em G-AD (0,650 ± 0,16 cm) foi significantemente maior do que o das tubas em G-PO (0,195 ± 0,04* cm) (p=0,01). Os testes de perviedade de pressão e corante foram negativos para todo o grupo PO e somente um animal em AD mostrou-se positivo para o teste de pressão. CONCLUSÃO: a aplicação histeroscópica de cianoacrilato no lúmen tubário de ovelhas impediu eficientemente a fecundação, constituindo procedimento eficaz e de boas perspectivas para aplicação futura em humanos.

Hysteroscopy and the butyl-cyanoacrylate on experimental sterilization of rabbit uterine tubes

PURPOSE: To assess the sterilization effectiveness on uterine tube of rabbit by the cyanoacrylate adhesive. METHODS: Hysteroscopy tubal catheterization was performed randomly in 12 animals (24 uterine tubes) assigned to the sham group (GS) and 15 animals (30 uterine tubes) to the n-butyl-cyanoacrylate (GB). The female rabbits were observed during 30, 90 and 180 days and mated to fertile males. The no pregnant rabbits were submitted to in vitro burst pressure test for patency by air insufflation (40 mmHg). The microscopic assessment was performed to parameters of damages in epithelium caused by the adhesive, the degree of inflammatory process, morphometry data values of tube diameter (UT) (cm), mucosa thickness (MT) and the myosalpinx thickness (MyT) (mm). The mucosa cells densitometry (total optical density) was expressed by the amount of DNA. The significance of the differences in histological scores and in thickness measurements were made by ANOVA test (P value < 0.05). RESULTS: In all animals of GB: the adhesive was attached to the mucosa; there was no pregnancy; no records of significant degree on inflammatory process; the patency test was negative and densitometry of DNA showed similar values to the both groups independently of observation periods. The layers thickness of GB-UT(1.118±0.117), GB-MT(0.447±0.247) and GB-MyT(0.853±0.097) were larger than the GS-UT(0.666±0.409), GS-MT(0.211±0.070) and GS-MyT(0.442±0.143). CONCLUSION: This approach offers a safe and feasible method of uterine tube obstruction.

Hysteroscopic sterilization with occlusion of sheep uterine tube using n-butyl-2-cyanoacrylate adhesive

PURPOSE: To evaluate the fertility and analyze the macroscopic, microscopic and morphometric aspects of sheep uterine tube sterilization with a hysteroscopically insert of n-butyl-2-cyanoacrylate adhesive. METHODS: 12 adult sheep, with one previous pregnancy, were distributed as follows: group L (n=3) subjected to laparotomy and Pomeroy uterine tube ligation, group S (n=3) subjected to hysteroscopic application of saline solution in tube isthmus and group AD(n=6), that was subjected to hysteroscopic application of 0.5 ml of n-2-butil-cyanoacrylate in tube isthmus. They were mated with fertile males for ninety days. The non pregnant sheep, at the 90th day, were subjected to laparotomy with uterus and tubes uterine resection. The fragments of uterine tubes were fixated in 10% formalin and processes for histology evaluated, and slices dyes for H.E. Data were evaluated by Wilcoxon and Mann-Whitney and Fisher's exact test. RESULTS: All sheep from groups L and AD did not get pregnant (0%) in contrast with sheep from group S (100%); the adhesive remained integral in the uterine tube lumen. The percentual of adherences (66.6%) and fibrosis responses (100%) was significantly higher in the group L than group AD (0%) (p<0.01). The diameter of the caudal tube in group AD (2652.15 ± 45.76 mm) was significantly wider than that of the group L (1868.27 ± 56.11* µm) (p < 0.05). CONCLUSION: The hysteroscopic insertion of cyanoacrylate in the uterine tube lumen of sheep was effective to obstruct the uterine tube and to promote the sterilization.

Transcervical sterilization

PURPOSE OF REVIEW

To discuss the methods for achieving success with currently available transcervical sterilization procedures for permanent female contraception.

RECENT FINDINGS

The transcervical approach has long been thought to be the optimal method for permanent female sterilization, with tubal access achieved by blind, direct (hysteroscopic) or indirect (radiological) techniques, and occlusion being achieved by chemical, mechanical, or thermal techniques. Some combination of these access and occlusion methods encompasses all the current procedures and two types predominate. Quinacrine sterilization is a procedure that is widely used in the developing world, while hysteroscopic procedures such as the Essure and Adiana procedures are either currently available or emerging as visually controlled, device-dependent methods for reliable transcervical sterilization that may be performed in an outpatient or office setting with minimal anesthesia and high patient acceptability. Other devices are used but have less supportive data for their continued use.

SUMMARY

Transcervical methods of female sterilization have good tubal access and occlusion rates, high patient acceptability, and can be performed in an outpatient setting. This combination of factors may offer significant advantages to traditional laparoscopic approaches and render them more cost-effective.

Innovations in contraception: a review

New forms of contraception have been developed to improve the safety and tolerability of contraceptive methods without compromising efficacy. The newest developments in contraception including low and ultra-low doses of estrogen, less-androgenic 19 nor-testosterone progestins, and the nonsteroidal progestin drospirenone, the Quick Start method to improve compliance of oral contraceptives, and the contraceptive transdermal patch, the vaginal estrogen-progestin ring, the levonorgestrel intrauterine system, and the hysteroscopic transcervical sterilization techniques are discussed.

Radiofrequency global endometrial ablation followed by hysteroscopic sterilization

STUDY OBJECTIVE

To describe the feasibility of performing Essure hysteroscopic sterilization immediately after NovaSure global endometrial ablation (GEA).

DESIGN

Descriptive feasibility study (Canadian Task Force classification III).

SETTING

Midwestern United States academic medical center.

PATIENTS

Twenty-five women (aged 35-49 years) with menorrhagia who elected GEA treatment and requested concurrent permanent sterilization.

INTERVENTIONS

NovaSure GEA followed immediately by Essure hysteroscopic sterilization. Patients returned 3 months after the procedure for hysterosalpingography (HSG) to document tubal occlusion.

MEASUREMENTS AND MAIN RESULTS

The inserts were placed successfully in all 25 patients; 21 returned for 3-month follow-up HSG, as recommended. Bilateral tubal occlusion was documented at 3 months in 19 patients (90%) and unilateral occlusion in 2 patients. Six-month postprocedural HSG in these 2 patients documented bilateral tubal occlusion. Hysterosalpingography was not performed in 4 patients. In all 21 patients with appropriate follow-up, complete occlusion was documented, and the ability to perform or interpret HSG was not affected by endometrial ablation.

CONCLUSION

Essure hysteroscopic sterilization can be safely performed after NovaSure GEA. Intrauterine synechiae do not appear to adversely affect the ability to perform HSG at 3 months or to document tubal occlusion.