Discordant relationship between Essure microinsert position and tubal occlusion

Abstract

Hysteroscopic sterilisation with Essure requires confirmation of tubal occlusion by hysterosalpingogram or microinsert position by transvaginal sonography 3 months after placement before women can rely on the method for pregnancy prevention. A 39-year-old woman underwent hysteroscopic sterilisation via Essure, with successful bilateral tubal occlusion documented on hysterosalpingogram. She had a subsequent unintended pregnancy and termination, and presented with persistent pelvic pain and other non-specific symptoms. She underwent a laparoscopic-assisted vaginal hysterectomy with bilateral salpingectomy, with complete resolution of her symptoms. Pathological evaluation demonstrated a perforated Essure microinsert and ipsilateral tubal occlusion, and a correctly placed Essure microinsert with ipsilateral tubal patency. Clinicians should be cautious about the assumption that correctly placed microinserts based on ultrasonography, hysterosalpingogram or laparoscopic evaluation assures occlusion success.

Figure 1

Transvaginal ultrasound revealing an appropriately positioned Essure microinsert (solid arrow) within the right fallopian tube; the microinsert on the left (open arrow) appearing to be in or through the myometrium.

Figure 2

Intraoperative laparoscopy view of the uterus, tubes and ovaries (A); gross uterine specimen in the intraoperative orientation (patient left on picture left) with both cornua opened, revealing (B); an Essure microinsert perforating the myometrium anterior to the left fallopian tube (C); and a microinsert within the lumen of the right fallopian tube (D).

Figure 3

Microscopic evaluation by H&E stain of fallopian tubes demonstrating a fibrosis-filled lumen of the left fallopian tube and (A) a patent right fallopian tube (B).