Hysterosalpingogram: an essential examination following Essure hysteroscopic sterilisation

Use of Hysterosalpingo-Foam Sonography for Assessment of the Efficacy of Essure Hysteroscopic Sterilization

OBJECTIVES

Hysterosalpingo-foam sonography (HyFoSy) has been suggested to be a possible less invasive alternative to hysterosalpingography (HSG), which is the reference standard for confirmation of tubal occlusion after Essure (Bayer AG, Leverkusen, Germany) hysteroscopic sterilization. The purpose of our study was to evaluate the accuracy of HyFoSy compared to HSG for confirmation of tubal occlusion after Essure hysteroscopic sterilization.

METHODS

A prospective study included 90 patients who underwent Essure hysteroscopic sterilization. Twelve weeks after the sterilization, 2-dimensional transvaginal ultrasonography was performed to assess the microinsert position and was followed by HyFoSy and HSG for evaluation of tubal occlusion. Patients with patent fallopian tubes on HSG were scheduled for additional HSG procedures at 3-month intervals until tubal occlusion was documented.

RESULTS

Of 90 enrolled patients, 86 patients with 170 fallopian tubes underwent the complete imaging protocol. Tubal occlusion was evaluated by HyFoSy as an index test and HSG as a reference standard. The accuracy of HyFoSy was 97.1% (95% confidence interval [CI], 93%-99%). The sensitivity and specificity were 100% (95% CI, 97%-100%) and 54.6% (95% CI, 23%-83%), whereas the positive and negative predictive values were 97.0% (95% CI, 93%-99%) and 100% (95% CI, 42%-100%), respectively. No long-term complications were reported for HyFoSy or HSG.

CONCLUSIONS

Given that the concordance rate for tubal occlusion between HyFoSy and HSG was not 100%, an occluded fallopian tube on HyFoSy should be confirmed by HSG, which remains the reference standard for confirmation of tubal occlusion after Essure hysteroscopic sterilization.

One-step transvaginal three-dimensional hysterosalpingo-foam sonography (3D-HyFoSy) confirmation test for Essure® follow-up: a multicenter study

OBJECTIVE

To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic insertion of an Essure® device, the feasibility and accuracy of three-dimensional (3D) transvaginal sonography (TVS) to check the position of the device and 3D hysterosalpingo-foam sonography (3D-HyFoSy) using contrast-enhanced gel foam to assess consequent tubal occlusion.

METHODS

This was a prospective multicenter study conducted from June 2012 to July 2014 in four Italian centers, which included 50 women who underwent hysteroscopic Essure microinsert placement in a total of 95 Fallopian tubes. Placement of the microinserts was performed in an outpatient setting following standard procedure recommendations. All patients underwent transvaginal 3D-HyFoSy and hysterosalpingography (HSG) approximately 12-14 weeks after the procedure. The position of the devices was first checked on 3D-TVS and classified according to specific criteria (Positions A, B, C and D). Then, 3D-HyFoSy with ExEm® gel foam as the ultrasound contrast agent was performed to confirm tubal occlusion by the absence of contrast agent within the tubes and/or around the ovaries. To evaluate the feasibility of 3D-HyFoSy, consecutive volume acquisitions were performed while injecting the gel foam. After sonographic evaluation, women underwent HSG to assess the success of sterilization, as standard methodology. Side effects and pain evoked during and after 3D-HyFoSy and HSG were evaluated using a numeric pain rating scale.

RESULTS

On 3D-TVS, 10 devices (10.5%) were in Position A, two (2.1%) in Position B, 59 (62.1%) in Position C and 24 (25.3%) in Position D. During 3D-HyFoSy, tubal occlusion was observed in 89 of 95 tubes (93.7%). In the six cases in which the passage of the contrast was observed, one device (16.7%) was in Position B, one device (16.7%) in Position D and four devices (66.7%) were found to lie in Position C. Tubal patency was confirmed at HSG with a concordance rate of 100%. The mean pain score associated with 3D-HyFoSy was significantly lower than that on HSG.

CONCLUSIONS

3D-TVS with HyFoSy allows accurate assessment of the position of Essure microinserts and tubal occlusion. It can be considered a safe, reliable, non-invasive alternative to HSG. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Ipsilateral Recurrent Tubal Ectopic Pregnancy Following a Salpingectomy

Sonographers are acquainted with the signs, symptoms, and findings of ectopic pregnancies as well as their recurrence; however, a recurrent ipsilateral ectopic pregnancy after a salpingectomy is also possible. While recurrent ipsilateral ectopic pregnancies are rare, they are a significant diagnostic discovery. It is important to highlight this rare manifestation and be aware of the potential for recurrent ipsilateral findings to avoid a misdiagnosis or prolonged treatment. The goal of this case study is to review a patient’s presentation and raise awareness of recurrent ipsilateral tubal ectopic pregnancy.

[What signs should you look for ultrasound (2D/3D) to affirm the good location of tubal implants? About a retrospective study of 92 cases]

OBJECTIVE

The aim of this study is to propose an analysis of the route and the curvature of the Essure^® system in 3D ultrasound to determine their correct location so as not to miss a tubal perforation.

METHODS

This is a retrospective single center study during 2 years analyzing 92 3D ultrasound performed by a single sonographer. Implant placement was performed by different operators. One prescribed 3D ultrasound control in case of difficulties with the installation; other indications where systematics.

RESULTS

The Essure^®'s position is right in 79% of cases. Twenty-eight implants appear incorrectly positioned on ultrasound 3D positioning. Abnormalities found are those described by the classification proposed in the literature. In one case, the curvature of the implant, not taking into account this classification, allowed to evoke a tubal perforation. Among the 28 cases of non-visualized implants in place, 3 cases of wrong position of the implant were confirmed by additional examinations (laparoscopy or HSG). For 14 cases, the ASP or HSG disproved the wrong position of the implants. In other cases, we did not have other complementary examinations.

CONCLUSION

Ultrasonography 3D seems to be the method of choice to control implants for simple implementation and good reproducibility. However, the interpretation of 3D ultrasound images is sometimes difficult. The study of the curvature of the implant should be systematically analyzed not to miss a tubal perforation.

Essure Microinsert Abdominal Migration after Hysteroscopic Tubal Sterilization of an Appropriately Placed Essure Device: Dual Case Reports and Review of the Literature

Background. The Essure device is a method of permanent sterilization widely used in the US that has proven to be safe and effective in most cases. However, there have been reports of device migration that have led to failed tubal occlusion as well as several other serious complications resulting from the presence of the device in the abdominal cavity. Case. This paper represents two cases of failed tubal occlusion by an appropriately placed Essure device without signs or symptoms of further complications related to device migration. Conclusion. Although there have only been 13 reported cases of abdominal device migration since November 2014, this case indicates that the actual number may be higher than reported since it is possible for migration to occur without additional complications. In the majority of reported cases of abdominal migration a major complication requiring surgical correction occurred, such as adhesions, small bowel obstruction, bowel perforation, or persistent pelvic pain. To avoid these complications it is recommended that migrating implants be removed; however, this case also represents an example of when a migrating device may remain in situ in an asymptomatic patient.

Evaluation of tubal microinserts position using 3D ultrasound and pelvic X-ray

PURPOSE

To retrospectively compare three-dimensional ultrasonography (3D-US) and pelvic X-rays to assess the position of tubal sterilization microinserts.

MATERIAL AND METHODS

Forty-four patients who underwent tubal sterilization with Essure(®) microinserts in our institution were included. The microinserts'position was evaluated three months after the procedure using 3D-US and pelvic X-rays. Placement on 3D-US was binary categorized as correct or incorrect and the distance between the two devices was reported. The orientation and symmetric deployment of the microinserts and the distance between the proximal parts of the two devices was assessed on pelvic X-rays. Performance of 3D-US and pelvic X-ray were compared using Mac Nemar test. Comparison of the distance between the two devices measured on pelvic X-rays and 3D-US was made with the paired Student t test.

RESULTS

3D-US images showed microinserts in 93% (41/44). Eighty-six percent (38/44) were correctly positioned on 3D-US and 82% (36/44) on pelvic X-rays. No significant differences between the performances of the two imaging techniques were found. No significant differences for the distance between the two devices measured on pelvic X-ray and 3D-US was found.

CONCLUSION

3D-US is a simple, non-ionizing technique, which appears as a promising alternate technique to pelvic X-rays to assess the correct position of Essure(®) microinserts.

Recurrent ectopic pregnancy in the tubal remnant after salpingectomy

We present two cases of ectopic pregnancy located within the remnant tube following ipsilateral salpingectomy. This particular pathology is rare and yet has significant consequences for the patient, with mortality rates 10–15 times higher than other ectopic pregnancies. It demonstrates that salpingectomy does not exclude ectopic pregnancy on the ipsilateral side. We suggest careful clinical consideration and bring attention to the current surgical technique.

Multimodality imaging of the Essure tubal occlusion device

The Essure device is a permanent birth-control device, which is gaining popularity. The micro-inserts are composed of metallic elements that can be seen on radiography, computed tomography, ultrasound, and magnetic resonance imaging. Knowledge of the normal location and appearance of the Essure device will ensure appropriate patient care. The purpose of this review is to describe the Essure tubal occlusion device and illustrate its normal and abnormal appearance using various imaging methods.

Necessity of hysterosalpingography after Essure microinsert placement for contraception

OBJECTIVE

The objective of our study was to determine whether hysterosalpingography is necessary after Essure microinsert placement by evaluating the rates of appropriate placement and of satisfactory tubal occlusion in a general population.

MATERIALS AND METHODS

We identified all patients who underwent hysterosalpingography after Essure microinsert placement for desired sterility between January 1, 2008, and August 1, 2010. We recorded demographic information and the hysterosalpingographic results. The images and operative reports of all cases with abnormal hysterosalpingographic findings were reviewed. The hysterosalpingographic results were reviewed for appropriate placement of the microinsert, for successful tubal occlusion, and for any additional abnormalities. We also reviewed the medical records for documentation of subsequent pregnancies.

RESULTS

Two hundred forty hysterosalpingographic examinations were performed after 237 hysteroscopic microinsert placement procedures in 235 women. The mean age of the subjects was 35 years (range, 20-50 years). Twenty-two examinations (9.2%) were abnormal. Fourteen (5.8%) revealed inappropriate placement: six with tubal occlusion, seven without tubal occlusion, and one with an indeterminate finding for tubal occlusion. Fifteen examinations (6.3%) showed tubal nonocclusion: Microinsert placement was inappropriate in seven cases and appropriate in eight. Of the 22 abnormal hysterosalpingographic examinations, 20 had operative reports available. Eleven (55%) described difficulties with device insertion. Forty-two endometrial abnormalities were described in hysterosalpingographic reports of 38 patients. One subsequent pregnancy was documented in a patient with satisfactory device placement and tubal occlusion on hysterosalpingography.

CONCLUSION

Hysterosalpingography after Essure microinsert placement is necessary because 6.3% of examinations showed abnormalities requiring an alternative form of contraception.