ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Hysteroscopic female permanent contraception

Hysteroscopic female permanent contraception
Literature review current through: May 2024.
This topic last updated: Dec 20, 2023.

INTRODUCTION — Female permanent contraception, also known as surgical sterilization, is a contraceptive method that blocks the passage of sperm through the fallopian tube. Laparoscopic sterilization is the main method for interval (ie, sterilization not performed postpartum) female permanent contraception. In the past, two hysteroscopic approaches to female sterilization were available, the Essure and Adiana systems. These systems are no longer marketed or available for use. However, clinicians should be familiar with them in order to care for patients who have undergone these procedures.

Hysteroscopic permanent contraception, including the Essure and Adiana systems, will be reviewed here. As the Adiana system was available for a shorter period of time, most of the data are from studies of the Essure system. Related discussions of female permanent contraception, laparoscopic and postpartum permanent contraception, and general selection of contraception are presented separately.

(See "Overview of female permanent contraception".)

(See "Female interval permanent contraception: Procedures".)

(See "Postpartum permanent contraception: Procedures".)

(See "Contraception: Counseling and selection".)

BACKGROUND — Nearly one-quarter of reproductive-age women globally use a form of permanent contraception, and it is the contraceptive method most commonly used by United States women [1,2]. For decades, laparoscopic permanent contraception was the gold standard for interval permanent contraception (ie, permanent contraception outside of the postpartum period). In an attempt to avoid the risks inherent in intraperitoneal surgery and provide a procedure that could be performed in an office setting, researchers worked to find safe and effective methods of transcervical hysteroscopic permanent contraception. In 2002, the Essure Permanent Birth Control system was approved by the US Food and Drug Administration (FDA) [3]; over 750,000 devices have been sold worldwide [4]. In 2009, the Adiana system for permanent contraception was approved by the FDA [5]. Both Essure and Adiana utilized a hysteroscopic approach to visualize the tubal ostia and insert a permanent device into the fallopian tubes to incite inflammation, leading to scar tissue formation and tubal blockage.

However, as of 2019, neither device is in production. Adiana was removed from the marketplace by its manufacturer in 2012 after a successful lawsuit by the manufacturer of Essure for patent infringement. Then, citing declining sales, likely in response to highly publicized litigation, the manufacturer of Essure withdrew their device from the marketplace in December 2018 [6,7]. As there are fewer data on Adiana given its shorter availability, the majority of this topic focuses on Essure.

Newer approaches to hysteroscopic (or transcervical) permanent contraception are under investigation [8,9]. The above experience with Essure highlights the need for adequate postmarketing surveillance research in addition to clinical trials that demonstrate clear benefit when the new device is compared with established contraceptive methods, such as intrauterine devices or progestin implants.

DEVICE TYPES

Essure

Device and procedure – The Essure Permanent Birth Control system utilized a hysteroscopic catheter threaded into each fallopian tube to deliver a nickel-titanium outer coil and a stainless steel inner coil wrapped with polyethylene terephthalate fibers (PET) (figure 1). After placement in the interstitial region of the tube, the outer sheath of the catheter was withdrawn, which allowed placement of the coil at the uterotubal junction, followed by expansion of the coil to fill the tubal lumen. Over several months, an inflammatory response to the device incited scar tissue formation with the goal of tubal occlusion [3].

Confirmation of tubal occlusion – Tubal occlusion was confirmed by a hysterosalpingogram (HSG) at three months postprocedure (image 1 and image 2). Patients were instructed to use alternative contraception until confirmatory testing showed bilateral tubal blockage [10].

In 2015, the US Food and Drug Administration (FDA) approved transvaginal ultrasound as an alternative to HSG to confirm coil placement but not tubal occlusion (image 3). Use of transvaginal ultrasound required additional training on the part of the operator and applied only to patients whose procedures were uncomplicated, lasted ≤15 minutes, and had one to eight outer coils visibly trailing into the uterine cavity [11].

Contraindications and complications – Contraindications to Essure included less than six weeks since last pregnancy, active or recent pelvic infection, uterine or tubal pathology blocking access to tubal ostia or tubal lumen, suspected unicornuate uterus, and known allergy to contrast media preventing ability to undergo HSG [3].

In 2016, the FDA added a black box warning stating that some patients with Essure implants experienced perforation of the uterus and/or fallopian tubes, identification of inserts in the abdominal or pelvic cavity, persistent pain, and suspected allergic or hypersensitivity reactions. Updated label warnings included irreversibility; the possibility of acute or persistent pain postprocedure related to unsatisfactory device location or other causes, especially among patients with a history of pain; that additional surgery would be required to remove the coils if needed; and that patients with a known hypersensitivity to nickel, titanium, platinum, stainless steel, or PET fiber may experience allergic reactions to the coil. In addition, the label advised that some patients could develop an allergy to nickel or other components of the insert following placement [4].

Adiana

Device, procedure, and confirmation – The Adiana permanent contraception system also utilized a hysteroscopic catheter threaded into each fallopian tube, followed by delivery of bipolar radiofrequency energy from the distal tip of the catheter to cause endothelial damage of the tubal lumen. A silicone matrix was inserted into each tube at the area of thermal damage to act as scaffolding for fibroblast growth and scar deposition. The scar tissue caused tubal occlusion, which was confirmed by HSG [5]. Patients were instructed to use alternative contraception until confirmatory testing showed bilateral tubal blockage.

Contraindications and complications – Contraindications for Adiana included less than 12 weeks since last pregnancy, active or recent pelvic infection, uterine or tubal pathology blocking access to tubal ostia or tubal lumen, suspected unicornuate uterus, known allergy to contrast media preventing ability to undergo HSG, and current use of immunosuppressive medications (eg, steroids) [5].

COUNSELING POINTS — A major limitation in evaluating the efficacy and safety of hysteroscopic permanent contraception is the reliance on low-quality data that overly rely on retrospective claims-based database analyses in the absence of adequate prospective, comparative, postmarket data collection and analyses.

Mechanism of action — Both abdominal and hysteroscopic permanent contraceptive procedures block the fallopian tubes to prevent passage of sperm and resultant fertilization of an egg. In hysteroscopic procedures, an operative hysteroscope was passed through the cervix and then a catheter or coil was inserted through the tubal ostia to initiate a process of fallopian tube scarring and resultant tubal occlusion over time (typically three to six months).

By contrast, open or laparoscopic permanent contraceptive procedures typically tie, cut, band, electrocoagulate, or remove the fallopian tubes. The contraceptive effect is immediate for abdominal procedures. (See "Female interval permanent contraception: Procedures".)

Efficacy — Although efficacy data are limited, real world pregnancy rates of 0.25 to 2.4 percent have been reported following hysteroscopic permanent contraception [12-16]. Some have estimated that up to one-half of all pregnancies after hysteroscopic permanent contraception are associated with nonadherence to follow-up hysterosalpingogram (HSG) [14]. Challenges to ascertaining true efficacy include use of claims databases (which may undercount miscarriage and abortion), relatively short duration of follow-up (one year or less), lack of direct comparison with established laparoscopic techniques, lack of mandatory pregnancy reporting, and suboptimal study methodology (eg, retrospective observational data and lack of intention-to-treat analysis) [12,17-19]. Efficacy data are mainly based on studies of the Essure device.

Representative data include:

Overall efficacy estimates – A 2013 systematic review of 24 studies (22 Essure, 2 Adiana) reported no pregnancies in 11 studies of approximately 1600 patients who had confirmed bilateral tubal occlusion by HSG or visualized insertion (time interval seven months to seven years) [13]. The other 11 Essure studies reported one or more pregnancies. A subsequent 2018 review extrapolated findings from the systematic review and estimated pregnancy rates after confirmed bilateral tubal occlusion to be 1.5 percent (99 pregnancies/6505 patients with confirmed occlusion) [14].

Caution should be exercised when evaluating reported pregnancy after hysteroscopic permanent contraception, as low failure rates are often reported from studies that only include patients with confirmation of bilateral tubal occlusion [14,20] and do not use intention-to-treat analyses. Additionally, because hysteroscopic permanent contraception is a multistep procedure that requires varying levels of patient adherence, failure rates should be reported as perfect compared with typical use, consistent with all other methods of contraception [12,19].

Compared with laparoscopic sterilization – Although data are mixed, pregnancy rates appear to be similar for the two surgical approaches if only patients with confirmed tubal occlusion following hysteroscopy are included, which is similar to a "perfect use" scenario for contraception [12,17,18]. However, when studies include subjects with inadequate follow-up imaging or coil placement (ie, "typical use"), hysteroscopic sterilization appears to be associated with a higher unintended pregnancy rate compared with laparoscopic procedures.

In a 2021 retrospective analysis of Medicaid insurance claims including over 29,000 patients undergoing permanent contraception procedures, those undergoing a hysteroscopic compared with laparoscopic procedure had lower cumulative rates of pregnancy (6.3 versus 7.2 per 100 patients-years; adjusted risk ratio 0.76, 95% CI 0.62-0.9) at five years of follow-up; pregnancy rates decreased over time in both groups [21]. As with laparoscopic sterilization, younger age (ie, 18 to 27 years) at time of hysteroscopic permanent contraception was associated with higher failure rates.

A 2018 retrospective cohort analysis of over 105,000 patients from France reported a decreased risk of pregnancy following hysteroscopic versus laparoscopic permanent contraception at one year of follow-up (adjusted hazard ratio [HR] 0.70, 95% CI 0.53-0.92) but similar risk by three years [18]. Among all patients who underwent a hysteroscopic procedure, the pregnancy rates were higher at one year for those who did not complete confirmatory testing for tubal occlusion compared with those who did (0.28 versus 0.16 percent, adjusted HR 1.49, 95% CI 1.01-2.19). Additionally, when the authors analyzed a composite outcome of "sterilization failure" (defined in this study as a composite outcome that included salpingectomy, second sterilization procedure, and pregnancy), sterilization failure was higher for those undergoing hysteroscopic compared with laparoscopic sterilization at both one year (4.8 versus 0.69 percent, adjusted HR 7.11, 95% CI 5.92-8.54) and three years (5.8 versus 1.3 percent, adjusted HR 4.66, 95% CI 4.06-5.34) postprocedure.

In a 2016 retrospective analysis of a United States commercial claims database, for 66 percent of patients who underwent hysteroscopic procedures and had confirmed tubal occlusion (ie, perfect use), the pregnancy rates were similar between hysteroscopic and laparoscopic permanent contraception groups. However, intention-to-treat analysis (ie, typical use) that included the entire study group reported higher pregnancy rates after hysteroscopic compared with laparoscopic approaches (2.4 versus 2 percent, adjusted HR 1.2, 95% CI 1.09-1.33; 27,724 hysteroscopic versus 42,391 laparoscopic procedures) [12]. Advantages of this study include the large number of participants, use of intention-to-treat analysis, and subanalysis of patients with confirmed tubal occlusion.

A 2015 retrospective cohort of claims data in New York state reported a similar risk of pregnancy at one year after hysteroscopic compared with laparoscopic permanent contraceptive procedures (adjusted odds ratio 0.84, 95% CI 0.63-1.12, 8048 hysteroscopic and 44,278 laparoscopic procedures) [17]. Study limitations included a relatively short follow-up period (one year) and noninclusion of any patients undergoing office hysteroscopic procedures.

Comparison with abdominal permanent contraception

Advantages – Hysteroscopic permanent contraception has several potential advantages over laparoscopic or open abdominal permanent contraception. It does not require incisions, can be performed in an office setting with local anesthesia, and avoids abdominal entry [22]. These differences may be particularly advantageous for patients desiring permanent contraception who have contraindications to abdominal surgery, Trendelenburg positioning, or general anesthesia. However, some analyses found that only 50 percent of hysteroscopic permanent contraceptive procedures were performed in the office, and 50 percent were still performed in the operating room with general anesthesia [12,17].

Disadvantages – The major disadvantage of hysteroscopic permanent contraception is that it is not immediately effective. Patients undergoing hysteroscopic permanent contraception must use alternative contraception until confirmatory testing proves bilateral tubal occlusion at three months postprocedure. If bilateral occlusion is not present at three months, contraception is continued, and a repeat HSG is performed three months later (six months postprocedure). Up to 6 percent of patients need a six month postprocedure HSG, and of those who return for the HSG, 93 to 100 percent will have bilateral occlusion [23]. This multistep procedure requiring use of alternative contraception and confirmatory testing of occlusion before being able to rely on it for contraception is unlike laparoscopic permanent contraception, which is immediately effective, but is similar to male sterilization (vasectomy). HSG follow-up rates range from 13 to 94 percent, depending on the study population [12,24-26].

Other — Neither hysteroscopic nor laparoscopic permanent sterilization procedures provide protection from sexually transmitted infections (STIs). Patients at risk for STI acquisition should be counseled regarding prevention options. (See "Prevention of sexually transmitted infections".)

No data exist on whether hysteroscopic permanent sterilization decreases the risk of ovarian cancer as has been previously reported for laparoscopic salpingectomy for permanent contraception [27]. One observational study that followed over 63,000 patients for up to seven years reported similar risk of gynecologic cancers following hysteroscopic and laparoscopic contraceptive procedures [28]. The numbers of specific cancers were too small for reporting by subtype of gynecologic malignancy. Role of salpingectomy for ovarian cancer reduction is discussed elsewhere. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)

PROCEDURE-RELATED ISSUES — Issues specific to hysteroscopic permanent contraceptive procedures included success of bilateral coil placement, need for repeat procedures, reliability rate, and immediate surgical complications (defined as being diagnosed within 30 days of the procedure).

Success of bilateral coil placement – At the time of its market removal, reported rates of successful bilateral coil placement on first attempt varied between clinical trials (96 percent [29]) and real world studies (92 to 99 percent [30]). These rates are an improvement from the approximately 86 percent successful bilateral insertion rates reported in the initial device trials [29-31] and 76 to 96 percent successful bilateral placement rates reported in real world Essure studies [24,25,31-39].

Need for repeat procedure – Overall, studies estimate that 4 to 8 percent of patients undergoing hysteroscopic permanent contraceptive procedures will have a second permanent contraceptive procedure, including repeat hysteroscopic or laparoscopic permanent contraception, compared with less than 1 percent of patients undergoing initial laparoscopic permanent contraception [12,18,23,24,39,40]. The risk of having a repeat procedure persists up to three years from initial insertion attempt [17,18]. In one large retrospective cohort study, of the patients who experienced an initial unsuccessful hysteroscopic permanent sterilization procedure and elected a second procedure, approximately two-thirds chose laparoscopic permanent contraception while approximately one-third desired a second hysteroscopic permanent contraceptive procedure [18].

Reliability of contraceptive efficacy – At three months postprocedure, 81 to 85 percent of patients can rely on the method for contraception [23,24,39]. Reliability increases to 84 to 88 percent at six months postprocedure [23,24]. Reasons for not being able to rely on the method (ie, having to use an additional form of contraception) include failed bilateral coil placement and failed tubal occlusion.

SHORT-TERM COMPLICATIONS AND OUTCOMES — Short-term complications may include bleeding, infection, tubal or uterine perforation, intraperitoneal migration (through a perforation or migration out the distal end of the fallopian tube), and device expulsion. Short-term surgical complications (not including reoperation to achieve permanent contraception) after hysteroscopic permanent contraceptive procedures are reported to be lower [17,18,40] or the same [39] as laparoscopic permanent contraception.

A study assessing 30 day surgical complications (eg, hemorrhage or hematoma complicating a procedure and accidental puncture or laceration) found fewer complications after hysteroscopic compared with laparoscopic permanent contraceptive procedures (adjusted odds ratio [OR] 0.35, 95% CI 0.2-0.6) [17].

A large retrospective cohort study that used national claims data from France and reported on complications identified during the hospital stay among 71,303 patients with hysteroscopic permanent contraception and 34,054 patients with laparoscopic permanent contraception, in multivariable analysis, hysteroscopic permanent contraception was associated with a lower risk of surgical complications (eg, abdominal injury) or medical complications (eg, stroke) than laparoscopic permanent contraception (adjusted OR 0.18, 95% CI 0.14-0.23 and adjusted OR 0.51, 95% CI 0.30-0.89, respectively) [18].

This difference in diagnosis of short-term surgical complications is likely due to the difference in types and severity of complications seen with hysteroscopic compared with laparoscopic permanent contraceptive procedures. For example, one of the more common complications of hysteroscopic permanent contraception, tubal perforation, may not be recognized during the procedure or soon after as it may not cause immediate signs or symptoms. Conversely, complications of laparoscopic permanent contraception, which tend to be more severe (eg, vessel perforation or bowel injury), are likely to be recognized sooner.

LONG-TERM COMPLICATIONS AND OUTCOMES — Long-term outcomes after hysteroscopic permanent contraception include method failure (ie, pregnancy and outcomes of those pregnancies), long-term surgical complications, menstrual dysfunction, pelvic pain, need for other related gynecologic surgery, and medical disorders. Limitations to understanding potential long-term outcomes after hysteroscopic permanent contraception include lack of prospective data directly comparing hysteroscopic and laparoscopic permanent contraception, inclusion of small sample sizes, and lack of intention-to-treat analyses. Nevertheless, important insights can be gained from existing data. As Adiana was available for less than three years, data regarding complications with Adiana are sparse.

Pregnancy and outcomes after contraception failure — When pregnancy occurs after hysteroscopic permanent contraception, the presence of the coils does not appear to increase the risk of poor obstetric outcomes, such as spontaneous abortion or preterm delivery, compared with pregnancy that occurs after laparoscopic permanent contraception, even after fertility treatment.

A study from a United States national claims database that evaluated 70,115 patients who underwent either hysteroscopic or laparoscopic permanent contraceptive procedures reported the following [41]:

A total of 997 pregnancies occurred in 817 patients after either hysteroscopic (387 pregnancies/27,724 cases) or laparoscopic (610 pregnancies/42,391 cases) permanent contraceptive procedures.

Sixty percent of pregnancies resulted in live birth. Live birth was more common after hysteroscopic compared with laparoscopic permanent contraception (0.27 versus 0.22 per 100 person-years).

Rates of preterm birth and spontaneous abortion were similar for the two groups, while induced abortion was more common in patients with hysteroscopic permanent contraception (0.12 versus 0.08 per 100 person-years).

Rate of ectopic pregnancy was less common following hysteroscopic procedures (0.01 versus 0.07 per 100 person-years).

In an interim analysis of results from a prospective comparison study mandated by the US Food and Drug Administration (FDA) and including 528 patients undergoing permanent contraception and completing at least one year of follow-up, those who underwent Essure (50 percent of patients) had a cumulative probability of pregnancy of 1.1 percent at 12 months and beyond; the cumulative probability of pregnancy in the laparoscopic permanent contraception group was 0.9 percent at 12 months and beyond [42,43]. The five-year follow-up of patients in the study is ongoing. As this study is descriptive, it is not designed or powered to detect statistical differences between the two groups; furthermore, final conclusions should not be made until the study is completed and final adjudication of the data is performed.

Additionally, pregnancies after hysteroscopic permanent contraception reversals have been reported [44]. Most patients who desire pregnancy after the procedure require in vitro fertilization (IVF). While there are few data, it appears that coil presence in the tubes does not diminish IVF success rates [45,46].

Other long-term surgical complications — Other than contraceptive failure (ie, pregnancy), the most commonly reported complications after hysteroscopic permanent contraceptive procedures are malposition or expulsion of coils, tubal perforation, and possible intra-abdominopelvic placement of coils with possible bowel injury [47-49]. Challenges to accurate assessment of complications includes use of claims databases [12,17,18], limited long-term follow-up [42], and limited sample sizes following Essure removal from the market [43].

For example, it is estimated that uterine or tubal perforation occurs in 1 to 3 percent of hysteroscopic permanent contraceptive procedures [22,50]. Perforation during or following coil placement may be asymptomatic, may present as pelvic pain, or may be discovered during the evaluation of a postprocedure pregnancy [51,52]. As there is no specific International Classification of Disease, ninth edition (ICD-9) or Current Procedural Terminology (CPT) code associated with perforation from hysteroscopic permanent contraception, related diagnoses are used to identify these patients.

Menstrual dysfunction — While conflicting data exist as to the relative impacts of hysteroscopic versus laparoscopic permanent contraception on menstrual dysfunction, larger data sets suggest that hysteroscopic procedures are associated with more menstrual abnormalities. Assessment of menstrual dysfunction is confounded by potential discontinuation of previously used hormonal methods of contraception, which may have treated or masked abnormal uterine bleeding (AUB) [53] and variations in definition of menstrual dysfunction, sample size, and duration of follow-up.

In the largest and most comprehensive retrospective analysis of menstrual dysfunction (anemia, posthemorrhagic anemia, disorders of menstruation, other abnormal bleeding from the female genital tract, and antepartum anemia) in a United States population, menstrual dysfunction was more common in patients after hysteroscopic compared with laparoscopic permanent contraception (26.8 versus 22.3 percent at two years, adjusted hazard ratio [HR] 1.23, 95% CI 1.2-1.27) [12]. Similarly, in the ongoing prospective comparative study discussed above (see 'Pregnancy and outcomes after contraception failure' above), the rate of anormal uterine bleeding at one year post procedure in the Essure group was 21.6 percent; the rate of abnormal uterine bleeding in the laparoscopic permanent contraception was 20.8 percent [42,43]. By contrast, a smaller Medicaid claims-based study that compared chronic AUB (one of two qualifying episodes of AUB had to occur at least three months postprocedure) and used fewer diagnostic codes to identify AUB reported no difference in AUB between the two groups at 24 months in post-matching analyses (adjusted odds ratio [OR] 1.06, 95% CI 0.93-1.21) [54].

Pelvic pain — Persistent pelvic pain has been reported after Essure placement in a minority of users (approximately 4 percent), is more likely in patients with prior chronic pelvic pain, and appears comparable to pelvic pain following laparoscopic procedures [12,55]. Symptoms of pelvic pain in Essure users may be attributed to suboptimal placement of the coils (eg, total or partial tubal perforation). For those patients with correctly placed coils, the mechanism of pain is unclear, but theories include tubal spasm from a foreign body or local or systemic reactions to the device components (eg, nickel or polyethylene terephthalate fibers) [56].

One retrospective cohort study (n = 458) reported that 4.2 percent of subjects had persistent pain three months after the procedure [55]. Patients with previous diagnoses of any chronic pain (chronic pelvic pain, chronic low back pain, chronic headache, and fibromyalgia) were more likely to report persistent pain (adjusted OR 6.15, 95% CI 2.1-18.1). In a different study that adjusted for underlying chronic pain (eg, preexisting pelvic pain, back pain, headaches), patients were not more likely to report pelvic pain, usually defined as dysmenorrhea, dyspareunia, ovulatory pain, low back pain, and other pain associated with gynecologic organs, at two years after hysteroscopic compared with laparoscopic permanent contraception (adjusted HR 0.83, 21 compared with 25.6 percent) [12]. By contrast, in the ongoing prospective comparative study discussed above (see 'Pregnancy and outcomes after contraception failure' above), the rate of pelvic pain at one year post procedure in the Essure group was 14.4 percent; the rate of pelvic pain in the laparoscopic permanent contraception group was 10.2 percent [42,43].

Need for other related gynecologic surgery — A retrospective study of a United States claims database assessed the incidence of additional gynecologic surgery after both hysteroscopic (n = 27,724) and laparoscopic (n = 42,391) permanent contraceptive procedures [12]. When followed for five years postprocedure and compared with patients who underwent laparoscopic procedures, those who underwent hysteroscopic procedures were:

More likely to have future hysteroscopic surgery (both diagnostic and operative procedures, such as endometrial ablation and hysteroscopic myomectomy; 17.5 compared with 13.4 percent at five years, adjusted HR 1.59, 95% CI 1.52-1.67).

Less likely to undergo subsequent laparoscopy (2.1 compared with 3.4 percent, adjusted HR 0.63, 95% CI 0.56-0.72) or hysterectomy (10.9 compared with 14.3 percent, adjusted HR 0.65, 95% CI 0.61-0.69).

As likely to undergo salpingectomy (1.7 compared with 2.2 percent, adjusted HR 0.9, 95% CI 0.78-1.05).

A retrospective study of over 105,000 French patients reported similar reduced risk of hysterectomy at one and three years of follow-up for patients undergoing hysteroscopic permanent contraception [18]. However, when the need for repeat permanent contraceptive procedures was included in the assessment for risk of reoperation, risk of repeat surgery was higher for hysteroscopic compared with laparoscopic permanent contraception (OR 6.2, 95% CI 2.8-14.0) [39].

Medical disorders after hysteroscopic permanent contraception — Limited available data suggest similar risks of developing a subsequent medical disorder following hysteroscopic or laparoscopic permanent contraceptive procedures. A database study of over 105,000 French patients reported similar risk for autoimmune disease and thyroid disorders at one and three years postprocedure [18]. When postprocedure medication use was assessed, use of antimigraine medication was similar between the groups while the risk of using analgesics, antidepressants, and benzodiazepines at three years was lower for patients receiving hysteroscopic procedures.

ESSURE REMOVAL — Limited data exist on indications, optimal procedures, and outcomes for Essure coil removal for patients who desire it. Prospective data, larger sample sizes, and longer follow-up periods are needed to inform both patients and clinicians about best practices for Essure removal and expected benefits of removal, which must be considered within the context of potential surgical risks. Available data are reviewed below.

Indications — The most common reason cited for removal is pelvic pain, and many patients cite multiple reasons [57,58]. Symptoms of pelvic pain are often attributed to suboptimal placement of the coils or to local or systemic reactions to the device components (eg, nickel or polyethylene terephthalate fibers) [57]. However, in a prospective study including 274 patients requesting Essure removal, the most common symptom reported was "extreme fatigue" (71 percent) [50]. In the ongoing prospective comparative study discussed above (see 'Pregnancy and outcomes after contraception failure' above), the overall cumulative probability of Essure removal for any reason was 10 percent at approximately 22 months of follow-up [42,43]. (See 'Essure removal' above.)

Prior to microinsert removal, patients should be fully evaluated for other potential causes of their symptoms. After a complete history and physical, imaging to evaluate the location of the coils is often the next step.

Asymptomatic patients may also present for consultation after imaging for other indications suggests malpositioning of the coils. If coils appear malpositioned (eg, on abdominal radiograph), a hysterosalpingogram (HSG) may need to be performed to confirm coil position and bilateral blockage. While asymptomatic perforation is often managed with coil removal, given the risk of scarring, migration, and potential damage to surrounding structures, data to guide optimal practice are lacking.

Procedures — Case series have described Essure removal via hysteroscopy, laparoscopy (usually salpingectomy), and laparotomy, with procedures including coil removal, salpingectomy with or without cornuectomy, and hysterectomy [58-63]. Prior to attempted removal by any method, imaging (ultrasound, HSG, or abdominal radiograph) is used to determine the location of the coils for surgical planning. Some reports have described starting with an ultrasound to verify correct tubal position of the Essure coils and absence of uterine anomalies with subsequent computed axial tomography or magnetic resonance imaging if coils are not visualized on ultrasound [57]. Intraoperative fluoroscopy to identify a coil that is difficult to locate or has perforated/migrated from the insertion site may be required [64]. Complete coil removal is confirmed by visualizing both the distal spherical and proximal rectangular ends of the intact Essure microinsert [57]. Choice of removal procedure should be guided by findings on imaging, timing since Essure placement, patients' desire for ongoing permanent contraception, presence of other underlying gynecologic conditions (eg, adenomyosis), and preferences for ovarian cancer risk-reducing salpingectomy [63].

Hysteroscopic removal – Hysteroscopic removal of microinserts is likely easiest in the few months after insertion, prior to the induction of fibrosis around the coils, which may then make the coils difficult to visualize hysteroscopically and more likely to fracture [63,65]. A hysteroscope with an operative channel is inserted into the uterine cavity, and a hysteroscopic grasper is used to gently tug (both the inner and outer) coils from the tubes as the scope is removed. A final view of the cavity should visualize no remaining pieces, and the coils should be inspected and counted for complete removal.

Laparoscopic removal – Laparoscopic removal has the advantage of allowing for a concomitant tubal ligation or salpingectomy to maintain the patient's desired permanent contraception. Laparoscopic removal may be indicated if the removal is longer than three months after insertion, there is concern for perforation or migration of the coils, the coils cannot be visualized hysteroscopically, or the patient desires laparoscopic permanent contraception [65,66].

Laparoscopic approaches that have been described include:

Salpingostomy with coil extraction – After placement of three 5 mm laparoscopic ports, the tube is placed on gentle traction, and the operator makes a linear 1 to 3 cm incision, with monopolar scissors or hook, along the tube starting at the cornua [57]. Once the coil is visualized, it is gently grasped with atraumatic forceps and pulled along its axis, out of the uterotubal lumen by systematically "walking" the coil out. Care should be taken to remove both inner and outer coils in their entirety by avoiding excess traction, which can elongate and uncoil the microinsert. After coil removal, a bilateral salpingectomy can be performed. Hysteroscopy is often performed to confirm no trailing coils remain in the uterine cavity.

Salpingectomy – Salpingectomy can be performed with the coil still in place using a bipolar cutting device [59]. The mesosalpinx is incised from lateral to medial, and then, the tube is amputated at its cornual attachment. The coils can then be seen and removed from the cornua [59].

Cornuectomy – Another method described in the literature involves performing a mini-cornuectomy by gently grasping and elevating the device using atraumatic forceps and monopolar scissors to make a small, circular cornual incision [57,67]. The proximal end of the coil is then visualized and removed without traction. The potential benefit of this approach is to minimize the risk of device fracture. After coil removal, a mini-resection of the uterine cornua to the level of the endometrium is performed along with a bilateral salpingectomy.

Hysterectomy – Hysterectomy with bilateral salpingectomy ensures complete coil removal. However, hysterectomy is generally not necessary without other indications, especially if laparoscopic removal is feasible. If the patient has indications for hysterectomy in addition to coil-related complications, this method is reasonable. Vaginal hysterectomy with en bloc removal of the hemiuterus without fragmentation of the inner and outer coils has been successfully reported in a series of 26 patients [62].

Complications — Surgical complications with Essure device removal can occur. In a literature review including 17 studies reporting on surgical complications after Essure device removal, laparoscopic salpingectomy compared with laparoscopic cornuectomy was associated with more device fractures (6.3 versus 2.7 percent) [63]. While no device fractures were reported with hysterectomy, other operative complications were more frequent and severe with hysterectomy compared with laparoscopic cornuectomy or laparoscopic salpingectomy (Clavien-Dindo classification grade 3: 8.1, 1.1, and 0.69 percent, respectively). In a subsequent prospective study detailed above (see 'Indications' above), of the 91 percent of microinserts removed by laparoscopic salpingostomy, insert extraction, or bilateral salpingectomy, minor complications were more frequent after compared with during the surgical procedure (3.9 versus 1.6 percent, respectively) [50].

Outcomes — Very limited information is available about patient and symptom outcomes after Essure removal. Studies are small, retrospective, lack a control arm, and are heterogeneous in terms of baseline symptoms, method of coil removal, outcome measured, and length of follow-up (six weeks to six months) [57,58,60]. Larger prospective, comparative studies with longer periods of follow-up are needed to inform patients about the expected symptom resolution after removal. We use the following studies as the basis for presurgical patient counseling regarding outcomes.

In a retrospective cohort study of 73 patients, 40 percent reported complete symptom resolution following removal of Essure coils [58]. Abdominal pain was the symptom prompting removal in 70 percent of patients. Ninety percent had coils removed laparoscopically (66 percent via bilateral salpingectomy). However, it should be noted that this cohort excluded patients with suspected perforation or device migration.

A prospective observational study of 80 symptomatic French patients undergoing laparoscopic removal of Essure and salpingectomy (with or without cornual excision) measured health-related quality of life at baseline and one, three, and six months after removal [57]. Patients reported significant improvements in mental and physical components of quality of life at one month after removal, which was sustained at three and six months. Patients also reported significant improvements in mean pain scores at one month following surgery compared with baseline (10 cm visual analog scale 3.6 [±0.36] to 1.4 [±0.25]) [57].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception" and "Society guideline links: Hysteroscopy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Permanent birth control for women (The Basics)")

Beyond the Basics topic (see "Patient education: Permanent birth control for females (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Background – Historical methods of hysteroscopic permanent contraception include Essure (figure 1) and Adiana devices. Although neither is available as new insertions as of 2019, patients who have had these devices inserted may present with questions or possible problems related to the devices. (See 'Background' above and 'Device types' above.)

Counseling points – A major limitation in evaluating the efficacy and safety of hysteroscopic permanent contraception is the reliance on retrospective claims-based database analyses in the absence of adequate prospective, comparative, postmarket data collection and analyses. (See 'Counseling points' above.)

Although efficacy data are limited, real world pregnancy rates of 0.25 to 2.4 percent have been reported following hysteroscopic permanent contraception. Some have estimated that up to one-half of all pregnancies after hysteroscopic permanent contraception are associated with nonadherence to follow-up confirmatory testing with hysterosalpingogram (HSG) or, in select cases, pelvic ultrasound. (See 'Efficacy' above.)

In intention-to-treat analyses, the "typical" failure (pregnancy) rate is higher after hysteroscopic compared with laparoscopic permanent contraception. (See 'Efficacy' above.)

Procedure-related issues – Procedure-related issues specific to hysteroscopic permanent contraceptive procedures include the need for repeat procedures, reliability rate (up to 88 percent at six months postprocedure), and immediate surgical complications. A second permanent contraceptive procedure is needed in approximately 4 to 8 percent of patients with a hysteroscopic permanent contraceptive device, compared with less than 1 percent of patients undergoing laparoscopic permanent contraception. (See 'Procedure-related issues' above.)

Short-term complications – Short-term complications from hysteroscopic permanent contraception may include the need for more than one surgical procedure to achieve permanent contraception; malposition or expulsion of coils; uterine or tubal perforation; and possible intra-abdominopelvic placement of coils with potential bowel injury, pelvic pain, expulsion of the device, or pelvic infection. (See 'Short-term complications and outcomes' above.)

Long-term complications – Long-term complications include device failure (ie, pregnancy), device migration, menstrual dysfunction, pelvic pain, and need for additional gynecologic surgery. (See 'Long-term complications and outcomes' above.)

Removal – For patients who desire removal of hysteroscopic contraceptive inserts, limited data exist on indications, optimal procedures, and outcomes. Prospective data, larger sample sizes, and longer follow-up periods are needed to inform both patients and clinicians about best practices. (See 'Essure removal' above.)

The most common reason cited for removal is pelvic pain. Symptoms of pelvic pain are often attributed to suboptimal placement of the coils or to local or systemic reactions to the device components (eg, nickel or polyethylene terephthalate fibers). (See 'Indications' above.)

Case series have described Essure removal via hysteroscopy, laparoscopy, and laparotomy. Procedures include coil removal, salpingectomy with or without cornuectomy, and hysterectomy. Prior to attempted removal by any method, imaging (ultrasound, HSG, or abdominal radiograph) is used to determine the location of the coils for surgical planning.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges James Greenberg, MD, and Amanda Yunker, DO, MSCR, who contributed to earlier versions of this topic review.

  1. Daniels K, Abma JC. Current contraceptive status among women aged 15–49: United States, 2015–2017. NCHS Data Brief No. 327, Centers for Disease Control and Prevention, 2018.
  2. Contraceptive Use by Method 2019: Data Booklet. United Nations; Department of Economic and Social Affairs, Population Division, 2019.
  3. Conceptus Inc. Essure System Premarket Approval Application P020014, Supplement S034. US Food and Drug Administration. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P020014S034 (Accessed on August 14, 2019).
  4. Essure Label. Bayer Inc. Available at: http://labeling.bayerhealthcare.com/html/products/pi/essure_pib_en.pdf (Accessed on August 14, 2019).
  5. Hologic Inc. Adiana Permanent Contraception System Premarket Approval Application P070022. US Food and Drug Administration. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf7/P070022B.pdf (Accessed on August 14, 2019).
  6. Conceptus(R) Announces Settlement of Patent Infringement Lawsuit With Hologic. April 30, 2012. https://www.globenewswire.com/news-release/2012/04/30/474765/253823/en/Conceptus-R-Announces-Settlement-of-Patent-Infringement-Lawsuit-With-Hologic.html (Accessed on August 13, 2019).
  7. Bayer Inc. Press Release. Bayer to voluntarily discontinue U.S. sales of Essure at end of 2018 for business reasons. Available at: https://www.bayer.us/en/newsroom/press-releases/article/?id=123229 (Accessed on August 20, 2019).
  8. Jensen JT, Hanna C, Yao S, et al. Transcervical administration of polidocanol foam prevents pregnancy in female baboons. Contraception 2016; 94:527.
  9. FemBloc Contraceptive Pivotal Trial. https://clinicaltrials.gov/ct2/show/NCT03433911 (Accessed on September 09, 2019).
  10. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 458: Hysterosalpingography after tubal sterilization. Obstet Gynecol 2010; 115:1343.
  11. Conceptus Inc. Essure System Premarket Approval Application P020014, Supplement S041. US Food and Drug Administration. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P020014S041 (Accessed on August 14, 2019).
  12. Perkins RB, Morgan JR, Awosogba TP, et al. Gynecologic Outcomes After Hysteroscopic and Laparoscopic Sterilization Procedures. Obstet Gynecol 2016; 128:843.
  13. Cleary TP, Tepper NK, Cwiak C, et al. Pregnancies after hysteroscopic sterilization: a systematic review. Contraception 2013; 87:539.
  14. Stuart GS, Ramesh SS. Interval Female Sterilization. Obstet Gynecol 2018; 131:117.
  15. Ríos-Castillo JE, Velasco E, Arjona-Berral JE, et al. Efficacy of Essure hysteroscopic sterilization--5 years follow up of 1200 women. Gynecol Endocrinol 2013; 29:580.
  16. la Chapelle CF, Veersema S, Brölmann HA, Jansen FW. Effectiveness and feasibility of hysteroscopic sterilization techniques: a systematic review and meta-analysis. Fertil Steril 2015; 103:1516.
  17. Mao J, Pfeifer S, Schlegel P, Sedrakyan A. Safety and efficacy of hysteroscopic sterilization compared with laparoscopic sterilization: an observational cohort study. BMJ 2015; 351:h5162.
  18. Bouillon K, Bertrand M, Bader G, et al. Association of Hysteroscopic vs Laparoscopic Sterilization With Procedural, Gynecological, and Medical Outcomes. JAMA 2018; 319:375.
  19. Gariepy AM, Creinin MD, Smith KJ, Xu X. Probability of pregnancy after sterilization: a comparison of hysteroscopic versus laparoscopic sterilization. Contraception 2014; 90:174.
  20. Dhruva SS, Ross JS, Gariepy AM. Revisiting Essure--Toward Safe and Effective Sterilization. N Engl J Med 2015; 373:e17.
  21. Gariepy AM, Lewis C, Zuckerman D, et al. Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study. Fertil Steril 2022; 117:1322.
  22. American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 133: benefits and risks of sterilization. Obstet Gynecol 2013; 121:392. Reaffirmed 2017.
  23. Gariepy AM, Creinin MD, Schwarz EB, Smith KJ. Reliability of laparoscopic compared with hysteroscopic sterilization at 1 year: a decision analysis. Obstet Gynecol 2011; 118:273.
  24. Chudnoff SG, Nichols JE Jr, Levie M. Hysteroscopic Essure Inserts for Permanent Contraception: Extended Follow-Up Results of a Phase III Multicenter International Study. J Minim Invasive Gynecol 2015; 22:951.
  25. Shavell VI, Abdallah ME, Diamond MP, et al. Post-Essure hysterosalpingography compliance in a clinic population. J Minim Invasive Gynecol 2008; 15:431.
  26. Leyser-Whalen O, Berenson AB. Adherence to hysterosalpingogram appointments following hysteroscopic sterilization among low-income women. Contraception 2013; 88:697.
  27. Falconer H, Yin L, Grönberg H, Altman D. Ovarian cancer risk after salpingectomy: a nationwide population-based study. J Natl Cancer Inst 2015; 107.
  28. Mao J, Guiahi M, Chudnoff S, et al. Seven-Year Outcomes After Hysteroscopic and Laparoscopic Sterilizations. Obstet Gynecol 2019; 133:323.
  29. Levie M, Chudnoff SG. A comparison of novice and experienced physicians performing hysteroscopic sterilization: an analysis of an FDA-mandated trial. Fertil Steril 2011; 96:643.
  30. Ouzounelli M, Reaven NL. Essure hysteroscopic sterilization versus interval laparoscopic bilateral tubal ligation: a comparative effectiveness review. J Minim Invasive Gynecol 2015; 22:342.
  31. Cooper JM, Carignan CS, Cher D, et al. Microinsert nonincisional hysteroscopic sterilization. Obstet Gynecol 2003; 102:59.
  32. Kerin JF, Carignan CS, Cher D. The safety and effectiveness of a new hysteroscopic method for permanent birth control: results of the first Essure pbc clinical study. Aust N Z J Obstet Gynaecol 2001; 41:364.
  33. Kerin JF, Cooper JM, Price T, et al. Hysteroscopic sterilization using a micro-insert device: results of a multicentre Phase II study. Hum Reprod 2003; 18:1223.
  34. Nichols M, Carter JF, Fylstra DL, et al. A comparative study of hysteroscopic sterilization performed in-office versus a hospital operating room. J Minim Invasive Gynecol 2006; 13:447.
  35. Ubeda A, Labastida R, Dexeus S. Essure: a new device for hysteroscopic tubal sterilization in an outpatient setting. Fertil Steril 2004; 82:196.
  36. Shavell VI, Abdallah ME, Diamond MP, Berman JM. Placement of a permanent birth control device at a university medical center. J Reprod Med 2009; 54:218.
  37. Savage UK, Masters SJ, Smid MC, et al. Hysteroscopic sterilization in a large group practice: experience and effectiveness. Obstet Gynecol 2009; 114:1227.
  38. Miño M, Arjona JE, Cordón J, et al. Success rate and patient satisfaction with the Essure sterilisation in an outpatient setting: a prospective study of 857 women. BJOG 2007; 114:763.
  39. Antoun L, Smith P, Gupta JK, Clark TJ. The feasibility, safety, and effectiveness of hysteroscopic sterilization compared with laparoscopic sterilization. Am J Obstet Gynecol 2017; 217:570.e1.
  40. Gariepy AM, Lewis C, Zuckerman D, et al. Patient-Centered Safety Outcomes After Hysteroscopic Compared With Laparoscopic Sterilization. Obstet Gynecol 2022; 139:423.
  41. Brandi K, Morgan JR, Paasche-Orlow MK, et al. Obstetric Outcomes After Failed Hysteroscopic and Laparoscopic Sterilization Procedures. Obstet Gynecol 2018; 131:253.
  42. US Food and Drug Administration. FDA Activities: Essure. https://www.fda.gov/medical-devices/essure-permanent-birth-control/fda-activities-essure#s3 (Accessed on March 02, 2022).
  43. US Food and Drug Administration. Essure Postmarket Study Surveillance. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pss.cfm?t_id=356&c_id=3854 (Accessed on March 02, 2022).
  44. Monteith CW, Berger GS, Zerden ML. Pregnancy success after hysteroscopic sterilization reversal. Obstet Gynecol 2014; 124:1183.
  45. Kerin JF, Cattanach S. Successful pregnancy outcome with the use of in vitro fertilization after Essure hysteroscopic sterilization. Fertil Steril 2007; 87:1212.e1.
  46. Mijatovic V, Veersema S, Emanuel MH, et al. Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization-embryo transfer in patients with a contraindication for laparoscopy. Fertil Steril 2010; 93:1338.
  47. Hurskainen R, Hovi SL, Gissler M, et al. Hysteroscopic tubal sterilization: a systematic review of the Essure system. Fertil Steril 2010; 94:16.
  48. Povedano B, Arjona JE, Velasco E, et al. Complications of hysteroscopic Essure(®) sterilisation: report on 4306 procedures performed in a single centre. BJOG 2012; 119:795.
  49. Adelman MR, Dassel MW, Sharp HT. Management of complications encountered with Essure hysteroscopic sterilization: a systematic review. J Minim Invasive Gynecol 2014; 21:733.
  50. Horsten DL, van Gastel DM, Maassen LW, et al. Perioperative findings and complications in Essure® removal surgery. Eur J Obstet Gynecol Reprod Biol 2021; 263:1.
  51. Langenveld J, Veersema S, Bongers MY, Koks CA. Tubal perforation by Essure: three different clinical presentations. Fertil Steril 2008; 90:2011.e5.
  52. Moses AW, Burgis JT, Bacon JL, Risinger J. Pregnancy after Essure placement: report of two cases. Fertil Steril 2008; 89:724.e9.
  53. Peterson HB, Jeng G, Folger SG, et al. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343:1681.
  54. Steward R, Carney P, Law A, et al. Long-term outcomes after elective sterilization procedures - a comparative retrospective cohort study of Medicaid patients. Contraception 2018; 97:428.
  55. Yunker AC, Ritch JM, Robinson EF, Golish CT. Incidence and risk factors for chronic pelvic pain after hysteroscopic sterilization. J Minim Invasive Gynecol 2015; 22:390.
  56. US Food and Drug Administration. FDA Review Document: Review of the Essure System for Hysteroscopic Sterilization. https://wayback.archive-it.org/7993/20170723124202/https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM463486.pdf (Accessed on September 12, 2019).
  57. Chene G, Cerruto E, Moret S, et al. Quality of life after laparoscopic removal of Essure® sterilization devices. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100054.
  58. Maassen LW, van Gastel DM, Haveman I, et al. Removal of Essure Sterilization Devices: A Retrospective Cohort Study in the Netherlands. J Minim Invasive Gynecol 2019; 26:1056.
  59. Lazorwitz A, Tocce K. A case series of removal of nickel-titanium sterilization microinserts from the uterine cornua using laparoscopic electrocautery for salpingectomy. Contraception 2017; 96:96.
  60. Clark NV, Rademaker D, Mushinski AA, et al. Essure Removal for the Treatment of Device-Attributed Symptoms: An Expanded Case Series and Follow-up Survey. J Minim Invasive Gynecol 2017; 24:971.
  61. Johal T, Kuruba N, Sule M, et al. Laparoscopic salpingectomy and removal of Essure hysteroscopic sterilisation device: a case series. Eur J Contracept Reprod Health Care 2018; 23:227.
  62. Charavil A, Agostini A, Rambeaud C, et al. Vaginal Hysterectomy with Salpingectomy for Essure Insert Removal. J Minim Invasive Gynecol 2019; 26:695.
  63. Chene G, Cerruto E, Merviel P, et al. Surgical techniques for the removal of Essure® microinserts: a literature review on current practice. Eur J Contracept Reprod Health Care 2021; 26:404.
  64. Howard DL, Christenson PJ, Strickland JL. Use of intraoperative fluoroscopy during laparotomy to identify fragments of retained Essure microinserts: case report. J Minim Invasive Gynecol 2012; 19:667.
  65. Albright CM, Frishman GN, Bhagavath B. Surgical aspects of removal of Essure microinsert. Contraception 2013; 88:334.
  66. Hur HC, Mansuria SM, Chen BA, Lee TT. Laparoscopic management of hysteroscopic essure sterilization complications: report of 3 cases. J Minim Invasive Gynecol 2008; 15:362.
  67. Thiel L, Rattray D, Thiel J. Laparoscopic Cornuectomy as a Technique for Removal of Essure Microinserts. J Minim Invasive Gynecol 2017; 24:10.
Topic 3277 Version 62.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟