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Objective: To compare perioperative and postoperative complications in patients who underwent opportunistic salpingectomy (OS) (removal of the fallopian tubes for ovarian cancer risk reduction during another surgery) at the time of cesarean section (C-section) with those in patients who underwent tubal ligation., Design: A population-based, retrospective cohort study., Setting: British Columbia, Canada., Patient(s): A total of 18,184 patients were included in this study, of whom 8,440 and 9,744 underwent OS and tubal ligation, respectively., Intervention(s): Patients who underwent OS during a C-section were compared with those who underwent tubal ligation during a C-section., Main Outcome Measure(s): We examined the perioperative outcomes, including operating room time, length of hospital stay, surgical complications such as infections, anemia, incision complications, injury to a pelvic organ, or operating room return; postoperative complications, including physician visits for a postoperative infection or visits that resulted in ultrasound or laboratory examinations and hospital readmissions in the 6 weeks after discharge; and likelihood to fill a prescription for antibiotics or analgesics., Result(s): The OS group had decreased odds of perioperative complications compared with the tubal ligation group (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.61-0.99). Patients who underwent OS did not have increased risks of physician visits for surgical complications, such as infection, or hospital readmissions in the 6 weeks after hospital discharge. In addition, these patients had 18% and 23% increased odds of filling prescriptions for nonsteroidal anti-inflammatory drugs (aOR, 1.18; 95% CI, 1.07-1.28) and opioids (aOR, 1.23%; 95% CI, 1.12-1.35), respectively., Conclusion(s): In this population-based, real-world study of OS at C-section, we report decreased perioperative complications and no difference in postoperative complications between patients who underwent OS and those who underwent tubal ligation. Patients who underwent OS had an increased likelihood of filling a prescription for nonsteroidal anti-inflammatory drugs and opioids in the 6 weeks after hospital discharge. This result should be interpreted with caution because we did not have data on over-the-counter medication use and, thus, not all prescription analgesics were captured in our data. Our data suggest that OS after C-section is a safe way to provide effective contraception and ovarian cancer risk reduction., Competing Interests: Declaration of interests K.G.A.R. has nothing to disclose. H.A.d.V. has nothing to disclose. J.N.M. reports honoraria from Merck and GSK and the ANZGOG Data Safety Monitoring Board from 2022 to present, outside the submitted work. C.E. has nothing to disclose. G.E.H. reports funding from the Canadian Institutes of Health Research, “The Effectiveness and Cost-Effectiveness of Opportunistic Salpingectomy for Ovarian Cancer Prevention,” obtained through a peer-reviewed project grant, a grant received from the Canadian Cancer Society Research Institute, and VGH & UBC Hospital Foundation funding for data access and research support for the submitted work., (Copyright © 2023 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare real-world effectiveness of hysteroscopic to laparoscopic sterilization., Design: Retrospective cohort of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical variables to examine the poststerilization pregnancy rates., Setting: Clinics, hospitals., Patient(s): Women aged 18-50 years with Medicaid claims between January 1, 2008, and August 31, 2014., Intervention(s): Hysteroscopic or laparoscopic sterilization procedure., Main Outcome Measure(s): Poststerilization pregnancy measured by pregnancy-related claims., Result(s): Among women with hysteroscopic (n = 5,906) or laparoscopic (n = 23,965) sterilization, poststerilization pregnancy claims were identified for 4.74% of women after hysteroscopic sterilization and 5.57% after laparoscopic sterilization. The pregnancy rates decreased over time after either procedure. Twelve months after the procedure, the crude incidence of pregnancy claims was higher for hysteroscopic sterilization than for laparoscopic sterilization (3.26 vs. 2.61 per 100 woman-years), but the propensity-weighted adjusted incidence rate ratio was 1.06 (95% confidence interval [CI], 0.85-1.26). Between 13 and 24 months after the procedure, there were fewer pregnancies for women after hysteroscopic sterilizations than for those after laparoscopic sterilizations (adjusted incidence rate ratio, 0.63 [95% CI, 0.45-0.88]), with no statistically significant differences in later years. The cumulative pregnancy rates 5 years after sterilization were lower with hysteroscopic sterilization than with laparoscopic sterilization (6.26 vs. 7.22 per 100 woman-years; propensity-weighted, adjusted risk ratio, 0.76 [95% CI, 0.62-0.90]). The poststerilization pregnancy rates varied by age and race/ethnicity., Conclusion(s): The pregnancy rates after female sterilization are higher than expected, whether performed hysteroscopically or laparoscopically. These findings are reassuring that the effectiveness of hysteroscopic sterilization was not inferior to laparoscopic sterilization., Clinical Trial Registration Number: NCT03438682., (Copyright © 2022 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To study the effects of the wide excision of soft tissues adjacent to the ovary and fallopian tube on ovarian function and surgical outcomes in women undergoing laparoscopic bilateral prophylactic salpingectomy., Design: Randomized, controlled trial., Setting: Teaching hospital., Patient(s): One hundred eighty-six women undergoing laparoscopic surgery for uterine myoma (n = 143) or tubal surgical sterilization (n = 43)., Intervention(s): Patients were randomly divided into two groups. In group A (n = 91), standard salpingectomy was performed. In group B (n = 95), the mesosalpinx was removed within the tubes. Prior to and 3 months after surgery, antimüllerian hormone (AMH), FSH, three-dimensional antral follicle count (AFC), vascular index (VI), flow index (FI), vascular-flow index (VFI), and OvAge were recorded for each patient., Main Outcome Measure(s): Ovarian reserve modification (Δ) before and after surgery was assessed as the primary outcome. Operative time, variation of the hemoglobin level (ΔHb), postoperative hospital stay, postoperative return to normal activity, and complication rate were assessed as secondary outcomes., Result(s): No significant difference was observed between groups for ΔAMH, ΔFSH, ΔAFC, ΔVI, ΔFI, ΔVFI, and ΔOvAge. Moreover, the groups were similar for operative time, ΔHb, postoperative hospital stay, postoperative return to normal activity, and complication rate., Conclusion(s): Even when the surgical excision includes the removal of the mesosalpinx, salpingectomy does not damage the ovarian reserve. Moreover, wide salpingectomy with excision of the mesosalpinx did not alter blood loss, hospitalization stay, or return to normal activities., Clinical Trial Registration Number: NCT02086370., (Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To demonstrate the feasibility of outpatient correction of Adiana proximal tubal occlusion by surgical implantation of the fallopian tubes., Design: Case study., Setting: Outpatient surgical center., Patient(s): A 36-year-old woman with a history of bilateral proximal tubal occlusion secondary to Adiana sterilization who desired surgical correction and natural conception., Intervention(s): Outpatient surgical correction of proximal Adiana tubal occlusion by use of a minilaparotomy to perform bilateral tubouterine implantation., Main Outcome Measure(s): Natural conception of pregnancy., Result(s): The patient underwent a successful outpatient bilateral tubouterine implantation to correct Adiana sterilization. The procedure was performed through a minilaparotomy abdominal incision by use of a posterior transfundal uterine incision to implant the isthmic sections of each tube into the uterine cavity. The patient's postoperative course was uncomplicated. Natural conceptions occurred at 6 and 9 months after surgery. The first pregnancy was of unknown location and aborted spontaneously. The second pregnancy was uncomplicated and was delivered at 39 weeks' gestation by elective cesarean delivery., Conclusion(s): Adiana hysteroscopic tubal occlusion can be surgically corrected in an outpatient setting through tubouterine implantation and this surgical technique can provide patients with an alternative to in vitro fertilization., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To highlight the fallacy of using a kink in the microinsert outline on plain abdominal x-ray as a marker for tubal perforation., Design: Case report., Setting: West London District general hospital., Patient(s): 36-year-old Asian woman requesting permanent sterilization., Intervention(s): Essure hysteroscopic sterilization followed by abdominal x-ray, pelvic ultrasound, and laparoscopy., Main Outcome Measure(s): Absence of tubal perforation., Result(s): A patient presented with clinically suspected fallopian tube perforation 3 days after Essure hysteroscopic sterilization. Her transvaginal scan was inconclusive, but the plain x-ray demonstrated a kink within the left microinsert outline. Diagnostic laparoscopy did not identify a perforation, and bilateral tubal placement was confirmed after salpingectomy., Conclusion(s): This case highlights the difficulty of relying on imaging in the acute setting to establish a diagnosis of tubal perforation after hysteroscopic sterilization., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the effectiveness and complication rate with Essure microinsert placements for tubal sterilization and the concomitant bipolar intrauterine surgical procedure., Design: Case control study., Setting: Department of gynecology and obstetrics of a general hospital in France., Patient(s): 382 women, including 41 undergoing one or several concomitant uterine procedures with Essure placement, and 341 undergoing Essure placement only (controls)., Intervention(s): Essure placement with or without bipolar hysteroscopic procedure for polyp, myoma, or endometrial ablation., Main Outcome Measure(s): Success rate for microinsert placement and complications at 3 months., Result(s): Forty-one patients had Essure microinserts placed in combination with a bipolar hysteroscopic procedure: endometrial resection (n=32), fibroma resection (n=4), or polyp ablation (n=5). They were compared with 341 patients who underwent Essure placement only. The success rate for Essure placement was 97.6% in the combination group versus 97.6% in the control group. The complication rate was 4.9% (n=2) in the combination group versus 2.6% (n=9) in the control group. The difference in the success and complication rates was not statistically significant., Conclusion(s): Performing intrauterine bipolar resection during hysteroscopy for sterilization is possible without reducing the Essure placement success rate and without increasing morbidity., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the x-ray appearance of Essure microinserts 5 years after their insertion., Design: Prospective controlled study., Setting: Tertiary referral centers for gynecologic care., Patient(s): Forty-five consecutive women with successful hysteroscopic bilateral placement of the Essure devices and postprocedure satisfactory hysterosalpingography confirmation test., Intervention(s): Pelvic anteroposterior x-ray., Main Outcome Measure(s): Stability and and symmetric appearance of Essure microinsert positions; measurement of the intrauterine distance between the two devices., Result(s): After 5 years from their placement, no detachment nor fracture of devices was observed. x-Ray recognition of the device after 5 years showed findings similar to those recorded at 3 months' follow-through hysterosalpingography., Conclusion(s): x-Ray evaluation of findings related to stability of position, symmetric appearance, and distance between the two Essure microinserts corroborates the irreversibility and the reliability of the fibrotic reaction that ensured tubal occlusion after devices placement., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the accuracy of three-dimensional (3D) ultrasound to determine the position of Essure microinserts., Design: Prospective observational study., Setting: Gynecology department in a teaching hospital., Patient(s): Forty women who underwent hysteroscopic sterilization from March through October 2008., Intervention(s): Both 3D ultrasound and hysterosalpingography (HSG) were performed 3 months after the procedure to verify device position. Positions seen on 3D ultrasound were classified in four categories: a perfect position (1 + 2 + 3), a proximal position (1 + 2), a distal position (2 + 3), and a very distal position (3-only). MAIN OUTCOME AND MEASURE(S): Microinsert position on 3D ultrasound and correlation with HSG., Result(s): Overall, 93% of the devices for 40 patients were found to have been placed successfully. The final sample comprised 64 Essure devices. HSG showed tubal patency for only three devices, all classified as 3-only. No tubal permeability was noted for the other 61 positions. This 3-only location on 3D ultrasound was statistically associated with a failure of sterilization in comparison with the other locations (3/16 [18%] vs. 0/48 [0%])., Conclusion(s): 3D ultrasound is a simple and reproducible technique to assess the position of the Essure microinsert and appears to protect most patients from the negative aspects of pelvic radiography and of HSG. Using the 3D ultrasound classification presented in this study appears to make it possible to use HSG for backup confirmation only when Essure is found to be in the 3-only position on 3D ultrasound., (Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To update the evidence of the efficacy and safety of the Essure system. Female sterilization has undergone changes in the last decade. Besides laparoscopic tubal occlusion, the Essure system is now a viable option, with about 200,000 women sterilized using this method., Design: The review is based on the report of the Alberta Heritage Foundation for Medical Research and completed with systematic literature searches up to April 8, 2008., Setting: The Managed Uptake of Medical Methods program of the Finnish National Research and Development Center for Health and Welfare., Patient(s): Women over 30 years, who had been sterilized by the Essure method., Intervention(s): Hysteroscopic tubal sterilization using Essure system., Main Outcome Measure(s): Efficacy/effectiveness, adverse events, costs., Result(s): Sterilization by Essure can be performed under local anesthesia or with oral analgesics in ambulatory settings. However, sterilization is not immediate and women must use additional contraception for 3 months until permanent tubal occlusion is verified by transvaginal ultrasound, hysterosalpingosonography, hysterosalpingography, or pelvic radiography. The evidence on efficacy and safety is mainly available from short follow-up case series but shows good efficacy and safety of the Essure system. Only a few small risks are associated with the procedure. Two economic studies, one of which implemented Essure as an in-office procedure, suggest that Essure could be more cost-effective than laparoscopic sterilization, but more information on the total cost is needed., Conclusion(s): The Essure system appears to be safe, permanent, irreversible, and a less invasive method of contraception compared with laparoscopic sterilization., (Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the data of cases of unintended pregnancies after Essure sterilization., Design: Retrospective case series analysis., Setting: National multicenter., Patient(s): Ten cases of unintended pregnancies after Essure sterilization in the Netherlands were reported from August 2002 through May 2008., Intervention(s): Data on the hysteroscopic Essure sterilization procedures and postprocedure confirmation tests of the reported cases were reviewed and analyzed by two authors. The causes of the unintended pregnancies were determined in agreement with the physicians who performed the sterilizations., Main Outcome Measure(s): Most pregnancies occurred in patients with only one device placement and bilateral occlusion on hysterosalpingography (HSG). Other cases included misinterpretation of HSG, undetected abnormal device position by ultrasound, one undetected preprocedure pregnancy, and two patient failures to follow up with the physician advice., Conclusion(s): The risk of pregnancy after hysteroscopic sterilization may be reduced by strictly following the follow-up protocol, performing a urinary pregnancy test on the day of the procedure, and instructing the patient to return for the follow-up visit. A procedure with only a single device placement in a patient without a history of tubectomy of the heterolateral tube should be considered unsuccessful., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess a new hysteroscopic method of tubal sterilization; specifically, to examine the factors associated with placement failure of Essure implants., Design: Observational, multicenter, 6-month study., Setting: Seven gynecology clinics, including five public hospitals and two private clinics, in France., Patient(s): A total of 495 women who provided informed consent., Intervention(s): All procedures were done by a vaginoscopic approach with a 5-mm operating hysteroscope., Main Outcome Measure(s): Data collected were age, parity, type of anesthesia, premedication, endometrial aspect, ostia visualization, duration of the procedure, pain during the procedure, and associated procedures. Unilateral and bilateral placement rates were assessed. Adverse events at 3 months (expulsion, migration, perforation) were also recorded., Result(s): Mean parity was 2.45; 20 women were nulliparous. In 56.3% of cases (n = 277), none or local anesthesia was used for the placement procedure. Overall, 86% of the women (n = 423) had nonsteroidal anti-inflammatory drug (NSAID) premedication, and 8.1% (n = 40) had another intrauterine surgical procedure performed at the same time. In 24 cases, at least one of the tubal ostia could not be visualized well during hysteroscopy., Conclusion(s): The failure rate for Essure micro-insert placement was 6% at first attempt and 3.3% after two attempts. Success rate was not significantly associated with parity, mode of analgesia, NSAID premedication, or combination with another procedure. The only factor significantly associated with the failure rate was poor visualization of the tubal ostia., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To present a case in which the use of a titanium/nickel microinsert in the management of unilateral hydrosalpinx contributed to a spontaneous intrauterine pregnancy., Design: Case report., Setting: University hospital., Patient(s): A 37-year-old nulligravid female with dense pelvic adhesive disease and unilateral hydrosalpinx., Intervention(s): Unilateral proximal occlusion of left fallopian tube with titanium/nickel microinsert., Main Outcome Measure(s): Pregnancy., Result(s): Spontaneous intrauterine pregnancy after confirmation via hysterosalpingogram of left tubal occlusion and right tubal patency., Conclusion(s): Transcervical proximal tubal occlusion using titanium/nickel microinserts provides an alternative in the management of hydrosalpinx in the setting of tubal factor infertility. Additionally, in the setting of a unilateral hydrosalpinx, unilateral occlusion can contribute to spontaneous intrauterine pregnancy.

By using the activity-based cost/management (ABC/M) system we computed and compared costs needed for laparoscopic tubal sterilization (LTS) and Essure hysteroscopic tubal occlusion (EHTO). We found that total health costs related to consultation and presurgery did not differ between LTS and EHTO; EHTO has low recovery unit costs but is more costly for the operating theater, mainly due to Essure microinserts.

Objective: To describe incorrect positions of Essure microinserts detected at 3 months' follow-up., Design: Case report., Setting: Outpatient department of obstetrics and gynecology in a Dutch teaching hospital., Patient(s): Initial series of 100 patients who underwent hysteroscopic sterilization using Essure between December 2003 and June 2004., Intervention(s): Hysteroscopic placement of the Essure System, follow-up at 3 months with transvaginal ultrasound (TVU), and hysterosalpingography., Main Outcome Measure(s): Bilateral placement rate, tubal obstruction, and detection of incorrect Essure microinsert localization at follow-up after apparent successful bilateral placement., Result(s): Bilateral placement of Essure microinserts in one session was successful in 93 women (93%). In 90 of these women (96.8%), tubal obstruction was proven at follow-up 3 months later. Three incorrect positions of an Essure insert were seen: two expulsions and one perforation into the abdominal cavity., Conclusion(s): Incorrect position of Essure microinserts was seen only when the initial placement procedure was difficult. When a placement procedure was difficult or other suboptimal conditions are present during the procedure, we advise performing a TVU or pelvic X-ray in these women 4 weeks after the procedure or after the first vaginal bleeding, instead of waiting for follow-up after 3 months.

A woman presented with symptoms of vaginal bleeding and pelvic pain shortly after hysteroscopic sterilization. Sonographic and hysteroscopic images of a dislodged Essure microinsert (Conceptus Inc., San Carlos, CA) are provided.

Objective: To report two cases of pregnancy after placement of Essure micro-inserts., Design: Case report., Setting: University-based Department of Obstetrics and Gynecology., Patient(s): Patient 1, a 38-year-old woman, presented with a positive pregnancy test 7 months after Essure hysteroscopic sterilization. Patient 2, a 35-year-old female, became pregnant approximately 1 year after undergoing the Essure procedure., Intervention(s): Patient 1 received obstetric ultrasounds, a prophylactic cerclage, a cesarean section, and a tubal ligation. Patient 2 underwent a postprocedure hysterosalpingogram, an obstetric ultrasound, pregnancy termination, diagnostic pelvic ultrasound, and a hysterectomy., Main Outcome Measure(s): Documentation of normal progress of pregnancy after Essure placement., Result(s): Patient 1 carried an uncomplicated pregnancy to term with an Essure micro-insert in place. Patient 2 became pregnant despite an hysterosalpingogram showing tubal occlusion and was ultimately found to have a micro-insert perforating the uterine wall., Conclusion(s): The presence of Essure micro-inserts in the fallopian tubes do not appear to interfere with implantation and pregnancy. Uterine perforation by an Essure micro-insert in proximity to the tubal ostia may mimic proper micro-insert placement and bilateral tubal occlusion on both hysterosalpingogram and saline infusion sonography.

Objective: To describe the use of Essure microinsert placement in patients with hydrosalpinges before IVF., Design: Retrospective case-series., Setting: An advanced endoscopic practice within a university-affiliated teaching hospital., Patient(s): Five women with unilateral or bilateral hydrosalpinges on transvaginal ultrasound, laparoscopy, or hysterosalpingogram who were planning further fertility therapy. In all patients, laparoscopy was felt to be relatively contraindicated because of previous extensive abdominopelvic surgery., Intervention(s): Hysteroscopic placement of the Essure microinsert in four patients under general anesthesia. One patient underwent fluoroscopically guided placement., Main Outcome Measure(s): Placement rates and postoperative recovery, technical challenges in Essure placement, and results of subsequent treatment with IVF when available., Result(s): Successful bilateral Essure placement was confirmed in two of five patients. Unilateral placement was achieved in two of five. There were no postoperative complications. No pregnancies have occurred thus far., Conclusion(s): Hysteroscopic placement of the Essure microinsert is a minimally invasive option for proximal tubal occlusion. In patients requiring occlusion of hydrosalpinges before IVF and with contraindications to abdominal surgery, this technique may offer a safer alternative. Preoperative documentation of proximal tubal patency helps predict placement success. Further research into this unique clinical scenario is required.

Objective: To evaluate the feasibility and safety of combining endometrial ablation (EA) with a thermal balloon endometrial ablation system (Gynecare Thermachoice IIIC Uterine Balloon Therapy System; Ethicon Inc., Somerville, NJ) and transcervical sterilization by intratubal insert (Essure Permanent Birth Control System; Conceptus, San Carlos, CA)., Design: Feasibility and safety studies., Setting: University hospital in Chihuahua, Mexico., Patient(s): There were 40 volunteers in the feasibility study and 9 in the safety study, all requiring hysterectomies for benign uterine bleeding., Intervention(s): In the feasibility study, both procedures were performed just before hysterectomy; in the safety study, thermocouples were inserted under the tubal serosa to assess heat transmission from the intratubal insert devices to the tubes and surrounding organs during EA., Main Outcome Measure(s): Completeness of EA and possible device dislodgement in the feasibility study; temperature readings in the safety study., Result(s): No disturbance of the intratubal insert devices was noted, and EA by the thermal balloon endometrial ablation system was complete visually and histologically, although small areas near the tubal ostia exhibited less endometrial destruction. Mean tubal temperatures ranged from 37.1 degrees C to 37.5 degrees C and did not reach the critical temperature of 45 degrees C. No damage to the tubes was noted., Conclusion(s): Performance of EA and sterilization with these two systems in a one-step approach is safe for women who require EA and permanent contraception.

Objective: To develop a technique for contrast infusion sonography and assess the possible use in determining microinsert placement and tubal status after Essure sterilization., Design: Techniques and instrumentation., Setting: Healthy women in an academic multispecialty group., Patient(s): Ten women desiring permanent sterilization who have recently undergone Essure hysteroscopic sterilization., Intervention(s): Contrast infusion sonography, an adaptation of hysterosalpingo contrast sonography, performed at 3-23 weeks after Essure placement., Main Outcome Measure(s): To determine how readily tubal status and microinsert location could be assessed with this adaptation of hysterosalpingo contrast sonography., Result(s): All microinserts were readily identified and tubal status was assessed by identification or absence of real-time contrast agent flow., Conclusion(s): This technique is very promising and could represent a convenient alternative to hysterosalpingogram (HSG) 3 months after Essure placement.

Objective: To determine the accuracy of ultrasound in the assessment of proximal fallopian tube positioning of the Essure microinsert coil 3 months after postprocedure., Design: Prospective cohort study (Canadian Task Force classification II-2)., Setting: Reproductive-age women in a tertiary care hospital., Patient(s): Reproductive-age women presenting with a request for permanent contraception., Intervention(s): Hysteroscopic sterilization with the Essure microinsert coil and conventional or volume-contrast three-dimensional (3D) ultrasound imaging 3 months after the procedure., Main Outcome Measure(s): Coil position on ultrasound., Result(s): Forty-eight of the 50 patients had successful placement of the Essure coils, and three patients required a second attempt on one tube. Conventional or volume-contrast (3D) ultrasound showed proper positioning of the coils within the proximal fallopian tube in 42 women (84%); five women (10%) required hysterosalpingogram to show appropriate positioning. Two patients (4%) required laparoscopic tubal sterilization, and one patient (2%) was lost to follow-up., Conclusion(s): Transvaginal ultrasound is an acceptable method of confirming proper placement of the Essure microinsert coil within the proximal fallopian tube 3 months after the procedure.

Objective: To assess the effectiveness and compatibility of an in situ-gelling polymeric device when implanted in the fallopian tube to prevent pregnancy., Design: Controlled laboratory study., Setting: Animals in a controlled laboratory environment., Animal(s): Ten white New Zealand rabbits (nine female and one male)., Intervention(s): The material was implanted through a small incision into one of each rabbit's twin fallopian tubes. The rabbits then were allowed to heal. After a healing period of 6 to 10 weeks, the rabbits were bred. After breeding, the animals were killed, and samples were collected from their fallopian tubes for histology., Main Outcome Measure(s): Pregnancy of the specimens., Result(s): Four specimens showed unilateral pregnancy (pregnancy in only one uterus). Because rabbits have the capacity to be pregnant in both uteri simultaneously, this suggests strong potential of the material for use as a contraceptive., Conclusion(s): Although concerns remain concerning distension and potential injury resulting from use of the system, enough data have been gathered to warrant further study of this material for use in humans.

Objective: To evaluate the results of hysteroscopic placement of an intratubal device for permanent birth control in 85 women in an outpatient setting., Design: Prospective, observational study., Setting: Private university hospital., Patient(s): Eighty-five premenopausal women who asked for tubal sterilization by hysteroscopy between July 2002 and July 2003., Intervention(s): Hysteroscopic placement of titanium-dacron intratubal devices in an outpatient setting., Main Outcome Measure(s): Procedure feasibility without anesthesia, success rate of device implantation, patient satisfaction, and confirmation of correct placement., Result(s): Successful placement was achieved in 81 patients (95%). Mean time elapsed between the start of hysteroscopy, placement of devices, and removal of optics was 9 minutes (range, 1-35 minutes). No intraoperative or postoperative complications were detected. Of 81 patients, 75 (93%) had abdominal x-ray performed at the third month; bilateral correct placement was confirmed in all of them., Conclusion(s): Essure is a safe, effective, and minimally aggressive procedure with satisfactory patient acceptance that does not require anesthesia or hospitalization. It seems to be a good alternative to laparoscopic tubal sterilization.

Objective: To determine the relative effectiveness of single vs. two transcervical monthly insertions of 252 mg of quinacrine for female sterilization., Design: Controlled clinical study., Setting: Family planning clinics of 6 academic centers., Patient(s): Sexually active reproductive-age women requesting sterilization., Intervention(s): At each of six centers 70 and 30 women were randomly assigned to receive either one or two, respectively, monthly transcervical insertions to the fundus of 252 mg of quinacrine and 75 mg of diclofenac as pellets and they were followed for 1 year., Main Outcome Measure(s): Complications, side effects, and pregnancy failures., Result(s): There were no serious complications and side effects were transient and easily treated. There were 31 (7.4%) pregnancy failures in the single insertions group and 2 (1.1%) in the two insertions group, but with marked center variation., Conclusion(s): Quinacrine sterilization using two monthly insertions of 252 mg of quinacrine appears safe and reasonably effective.

Objective: To determine the efficacy of a computer-controlled bipolar endotubal catheter system designed to accomplish safe, effective, and inexpensive female sterilization in preventing pregnancy in a rabbit model., Design: Prospective controlled study., Setting: University animal care facility., Animal(s): Sixty healthy virginal female New Zealand white rabbits., Intervention(s): Rabbits were assigned to the following groups: [1] endotubal radiofrequency minimal energy (95 degrees C) treatment; [2] endotubal radiofrequency maximal energy (105 degrees C) treatment; [3] endouterine radiofrequency (105 degrees C) treatment; [4] nonsurgical control; [5] laparotomy-only control; [6] endotubal radio-frequency sham control; and [7] external Kleppinger forceps bipolar cautery control. Rabbits were mated at 4 or 12 weeks after treatment., Main Outcome Measure(s): Pregnancy outcomes in treated animals and nontreated controls., Result(s): No pregnancies were observed in any of the uterine horns in which minimal or maximal energy was delivered to the fallopian tubes or uterus, although pregnancy occurred in one horn as a result of the delivery of energy below the radiofrequency minimum of 95 degrees C. The outcomes of the treatment groups were significantly different from those of the nonsurgical and sham surgical control groups., Conclusion(s): With adequate tissue heating, 100% sterilization efficacy was achieved with a new, computer-controlled bipolar catheter, whereas pregnancies occurred in all untreated control groups. If human studies support these results, the goal of a safe, effective means of transcervical sterilization may be realized.

Objective: To survey what factors influence the pregnancy outcome in an effort to improve the pregnancy rate (PR) after microsurgical reversal of tubal sterilization., Design: Retrospective clinical study., Patient(s): Three hundred eighty-seven patients who had microsurgical tubal reversal between March 1982 and January 1994., Intervention(s): Postoperative pregnancy outcomes were determined by telephone, letters, and direct interviews., Result(s): Pregnancy outcomes were identified in 94.1% of the total patients. The overall PR was 91.6%, of which 3.9% spontaneously aborted and 1.7% were ectopic. The probability that pregnancy occurred within the first 12 months was 0.80. The median interval from the tubal reversal to pregnancy was 5.34 months. The pregnancy success rate after reversal of Falope ring sterilization was statistically significantly higher than in the other groups. Patients with reversed tubal length > or = 7 cm had a statistically significantly higher PR than those with < 7 cm., Conclusion(s): The overall probability of pregnancy was 0.89. The tubal length reconstructed after tubal reversal and the type of sterilization performed previously were the important factors affecting the PR.

Objective: To review and evaluate a series of patients who underwent microsurgical anastomosis of previously sterilized fallopian tubes., Design: Retrospective clinical study., Setting: Tertiary care academic center., Patient(s): In the 134-month span from January 1980 to February 1991, 1,118 women were evaluated for microsurgical reversal of previous tubal sterilization., Main Outcome Measure(s): Clinical characteristics of patients, pregnancy rates (PRs), and factors influencing the outcome., Result(s): Of 1,118 patients, 633 (56.6%) had been sterilized by laparoscopic cautery. Loss of children was a leading reason for requesting tubal reversal. The mean interval between tubal sterilization and reversal was 51.9 months. Nine hundred twenty-two (82.5%) patients were followed up for > 5 years. The overall PR after microsurgical tubal anastomosis was 54.8% (505 of 922) with a delivery rate of 72.5% (366 of 505), and the estimated anatomical success rate was 88.2% (814 of 922). There was no statistically significant difference in the PR or in the interval from tubal reversal to conception among the different operative procedure groups. In addition, no statistically significant difference in the PR was observed regardless of the postoperative tubal length. However, the interval from operation to pregnancy decreased significantly as the postoperative tubal length increased. The pregnant patients (n = 505) were younger and had a longer postoperative tube than the nonpregnant patients (n = 417); these differences were statistically significant., Conclusion(s): The pregnancy rate after microsurgical reversal of tubal sterilization was not significantly correlated with the method and duration of sterilization, the operative procedure, or the postoperative tubal length.

Objective: To determine the prognosis for pregnancy when tubal anastomosis can be performed on only one tube., Design: Prospective collection of demographic and clinical data., Setting: University medical center., Patient(s): One hundred twenty-six women undergoing elective sterilization reversal., Intervention(s): Sterilization reversal was performed by five reproductive endocrine surgeons. In 35 cases, only one tube could be treated surgically. In all cases, this was because of a previous salpingectomy or inadequate distal tubal segment., Main Outcome Measure(s): Cumulative probability of pregnancy in the two groups (one tube or two tubes) was analyzed by survival analysis and logistic regression. Survival curves were compared by log-rank testing., Result(s): Comparison of survival curves revealed no difference between the logistic regression curves for probability of conception after anastomosis of one tube versus two tubes. Logistic regression revealed a similar cumulative probability of conception with a two-tube (0.76) and a one-tube anastomosis (0.63). The monthly fecundity rates were 0.032 and 0.034 for a two-tube and one-tube anastomosis, respectively. There were no differences between the groups with respect to age, gravidity, or parity. Virtually all pregnancies occurred within 2 years of surgery., Conclusion(s): The prognosis for conception after one-tube anastomosis was the same as for two-tube anastomosis.

Objective: To describe a new technique for open laparoscopy., Design: Prospective case series., Setting: Ambulatory surgical unit., Patient(s): Fifty-six women undergoing laparoscopic sterilization., Intervention(s): Intra-abdominal placement of an optical surgical obturator., Main Outcome Measure(s): Evaluation of surgical technique., Result(s): The technique was completed successfully in all cases., Conclusion(s): This new surgical approach may assist surgeons in avoiding inadvertent injuries.

Objectives: To investigate the usefulness of the Ramathibodi uterine manipulator (AMZURA Enterprises, Freeport, NY) in performing laparoscopic sterilization procedures in the supine position under local anesthesia., Design: Descriptive prospective study., Setting: Ambulatory surgical unit of university-affiliated hospital., Patients: Women presenting for elective sterilization and weighing < 110 kg., Intervention: The Ramathibodi uterine manipulator was used to provide uterine manipulation in 85 cases of laparoscopic sterilization, all performed in the supine position as local anesthesia-sedation sterilization operations. Because such procedures are becoming more common worldwide, we propose the acronym "LASSO" (Local Anesthesia-Sedation Sterilization Operation) for this class of operations. Although commonly used in minilaparotomy procedures, use of this uterine manipulation device in laparoscopic procedures has not been published previously., Main Outcome Measure: Successful tubal occlusion., Results: Among the 85 cases reported here there were no failures to manipulate the uterus successfully, to identify the tubes, and to occlude them., Conclusions: The simplicity of the Ramathibodi uterine manipulator provided several advantages over other means of uterine manipulation, notably [1] constant easy-to-learn maneuvers, [2] no tenaculum or balloon requirement, [3] the procedure could be performed in the supine position, and [4] there are no working parts, screws, or springs that could be lost or broken by operating room staff. Our experience with this device leads us to recommend it to colleagues as an inexpensive, safe, and effective alternative to currently available instruments for providing uterine elevation during laparoscopic sterilization procedures.

Objective: To evaluate the influence of laparoscopic sterilization by Falope-rings (Cabot Medical Corp., Langhorne, PA) or Filshie-clips (Femcare, Nottingham, United Kingdom) on menstrual pattern and ovulatory function., Design: A prospective, nonrandomized study of women sterilized by Falope-rings (n = 6) or Filshie-clips (n = 5). Menstrual charts were kept. Serum follicle-stimulating hormone (FSH), estradiol (E2) and progesterone (P) were measured by means of radioimmunoassay in one cycle before and 3, 6, and 12 months after the sterilization. Blood samples were drawn on day -6, -2, 0, +6, +10 of the menstrual cycle, ovulation corresponding to day 0. The women sterilized by Filshie-clips had abdominal ultrasonography of the ovaries measuring the leading follicle on day -6, -2, 0, +6 of the menstrual cycle., Patients: Twelve women, 25 to 38 years old, with regular menstrual cycles and no use of oral contraceptives or intrauterine contraceptive device at least 6 months before sterilization. One woman was excluded., Results: After the sterilization, all women reported unchanged menstrual pattern. The follicular rise in E2 unchanged, and FSH levels fell accordingly. Progesterone levels were ovulatory, but the midluteal P peak 3 months poststerilization was significantly decreased. Serial abdominal ultrasonography in women sterilized by Filshie-clips confirmed ovulation in all cycles except in one woman, who had an unruptured follicle in one cycle before and in the sixth cycle after sterilization., Conclusion: Laparoscopic sterilization by Falope-rings or Filshie-clips does not seem to interfere with menstrual pattern or ovulatory function.

In this study, fimbriectomy reversal resulted in a 43% intrauterine PR and a fecundability of 6.6%. The cumulative PR and the fecundability were 57% and 7.8%, respectively, when microsurgery was augmented by GIFT and embryo cryopreservation during the same treatment cycle and by subsequent embryo thaw and transfer.

Restoration of tubal patency after surgical sterilization in which the luminal continutiy is interrupted requires either uterine implantation of the patent distal segment or resection and end-to-end anastomosis of patent adjacent segments. Although it is logical to assume that after most tubal ligations the intramural segment remains normal and end-to-end anastomosis is possible, both segments should be evaluated and tested prior to the plastic reconstruction. The results of 178 operations collected from the literature and the author's 23 attempts at surgical reversal of previous tubal operations for surgical sterilization were described. The over-all pregnancy rate after resection and end-to-end anastomosis was 39.0%; after uterotubal implantation, it was 19.4%. The latter procedure was performed in 60% of the patients. The small series of reports makes it difficult to evaluate conception rates or to judge the merits of specific reconstructive operative techniques.

Forty-five puerperal inverted V Weck clip applications have been completed with either the Samuel's or (modified) Weck pistol-grip applicator. Of the 45 applications, 31 have been followed for 25 to 36 months (69%), 12 have been followed for 13 to 25 months (27%), and 2 have been followed for 9 to 12 months (4%). The failure rate thus far is 2.2%. No mechanical difficulties were encountered with the Samuel's or the (modified) Weck pistol-grip applicator. Reversibility has been observed in one interval patient, while pre-admission evaluation of a puerperal patient suggests postremoval tubal patency.

Seventy-six women requesting reversal of sterilization underwent at least 1 operative procedure during a 27-month period, and 14 (18.4%) were found to have pelvic endometriosis. The endometriosis patients were noted to have had significantly fewer pregnancies (1.8 versus 2.9, P less than 0.01) before sterilization than those without endometriosis, but the two groups did not differ significantly in mean age (30.8 versus 30.3 years), type of sterilization or in mean number of years since sterilization (5.0 versus 5.5 years). In only two individuals were proximal tubal segment fistulas found at the time of reversal, and neither had endometriosis. We conclude that pelvic endometriosis is more common in patients with bilateral tubal occlusion than previously suspected and that its presence indicates that endometriosis implants can persist for prolonged periods of time, can give rise to new implants, or do not require the tubal reflux of menstrual debris to form.

In a series of 247 consecutive sterilizations by fimbriectomy performed at the Denver General Hospital, a failure rate of 2.4% was found. The literature is reviewed, and these results are compared with results of other series. In several of the fimbriectomy series with more successful outcome, modifications of the technique originally described were used. The difficulties associated with the Kroener technique are discussed. The fimbriectomy failures were caused by either lack of resection of all of the fimbriae or the presence of tuboperitoneal fistulas, both congenital and acquired. Fimbriectomy should not be regarded as the method of choice for sterilization unless one can ensure adequate surgical exposure and complete removal of the fibria, including the fimbria ovarica.

A spring clip designed to be applied to the fallopian tube for sterilization without electrocoagulation was applied to 10 pigs. After documenting the prevention of pregnancy for 3 months, the clips were removed and successful reanastomosis was performed on eight pigs. Six of these pigs became pregnant within 2 months of the reanastomosis. This paper describes the technique of the reanastomosis and documents the potential reversibility of spring clip sterilization.

Laparoscopic tubal sterilization has been rapidly gaining acceptance as a nonpuerperal method of permanent fertility control. A number of problems have nonetheless been associated with this technique. For example, tubal destruction often exceeds that necessary for tubal occlusions, increasing the danger of thermal injuries and possibly such dysfunctional disorders as abnormal uterine bleeding and dysmenorrhea. Furthermore, excessive destruction precludes any possibility of later tubal reconstruction. In an attempt to avoid these problems, a new low-voltage unit with a rechargeable battery was evaluated. With this unit, cautery is provided under laparoscopic view with a spring-activated hook which retracts the fallopian tube into a Teflon shield, where it is coagulated and transected. Histopathologic studies of the healthy fallopian tubes of four women in their reproductive years treated by this method while the abdomen was open prior to an elective hysterectomy demonstrated minimal destruction of the mesosalpinx, with complete tubal occlusion and a coagulated area 10 mm in length. One hundred and sixty-five patients have been sterilized successfully by this method. Indications are that it may provide safe tubal occlusion without unnecessary destruction of the fallopian tubes and surrounding vasculature.

This paper reviews the results of attempted tubal reconstruction following laparoscopic sterilizations using the electrocoagulation and excision technique in the isthmic portion of the fallopian tube. The surgical technique, complications, and results are presented.

In response to large numbers of requests for laparoscopic sterilization, the University of North Carolina began a training program to provide this service on a regional basis throughout the state. This report reviews the final distribution of centers providing these services: one within 50 miles of every person in the state. The clinical experience of 30 private physicians (excluding experience of residency training programs) was reviewed and found to parallel the national experience in provision of services, in complications, and in pregnancies. The brief but intense training program (2 days at the University of North Carolina and one morning at the physician's hospital) was found to result in rates of complications and failures similar to national levels of performance. Should the demand for laparoscopic sterilization increase in the coming years, the region has sufficient numbers of safely trained physicians to respond.

A preliminary report is given on a new laparoscopic sterilization procedure. By a double-puncture method, a loop of tube is brought out of the abdomen through the suprapubic incision. The loop is then resected by a modified Pomeroy method. Between Octorber 1976 and June 1978, 75 sterilizations were performed without any major problem. Sterilization failed in one case when one tube could not be seen. All recoveries were uneventful. Safety, effectiveness, simplicity, and potential reversibility seem to be the qualities of this method.

In 1977 we reported on seven patients who presented with intrauterine pregnancy in spite of previous fimbriectomy; in a detailed morphologic study one tuboperitoneal fistula was documented in each of four patients. In the present study three more patients are reported with pregnancy following fimbriectomy, and another four tuboperitoneal fistulas are morphologically investigated and their possible etiology is discussed. In spite of a failure rate of almost 2.6%, the concept about the reliability of fimbriectomy need not necessarily be condemned. This concept can be judged only if information is available both about the total number of fistulas subsequent to a certain technique and about the number of those fistulas which contributed to pregnancy.

An outpatient sterilization program was started at Silas B. Hays Hospital, Fort Ord, California, and later extended to Malcolm Grow USAF Medical Center and the Walter Reed Army Medical Center. From January 1976 to June 1978, two hundred and eight outpatient minilaparotomy Pomeroy tubal ligations were performed under local anesthesia. The minilaparotomy technique, using standard operating room equipment, is described. The average operating time was 31.8 minutes and the complication rate was 2.5%.

Twelve different sizes of elastic bands were tried in animal experimentation for tubal sterilization. Reversible sterilization was not successful in any of the animals after removal of the various-sized bands. A new elastic Silastic band is reported which is larger and wider than those previously described. Over a 4-year period, no serious complications have been reported and extremely low pregnancy rates have been achieved by utilizing the new, wider bands and our applicators for human sterilization.