Essure Reversal

Essure Sterilization Reversal

It is a common belief Essure sterilization cannot be reversed. Although Essure is intended to be permanent, we have surgically reversed Essure at our center and have been able to provide our patients with a reasonable alternative to in vitro fertilization.

The Essure micro-inserts cause proximal occlusion of the fallopian tube. Proximal occlusion of the fallopian tube can be surgically corrected utilizing tubouterine implantation.

Women have had proximal occlusion of the fallopian tubes from other reasons before Essure ever existed. At our center the most common, naturally occurring reason for proximal blockage of the fallopian tube is Salpingitis Isthmica Nodosa. The most common reason we perform tubouterine implantation at our center is to surgically correct tubal sterilizations performed immediately adjacent to the uterus. This is most commonly encountered with tubal coagulation type tubal ligations. We have been performing tubouterine implantations to correct proximal tubal blockage before the FDA approved Essure in 2002.

Tubouterine implantation

A long history

The first report of tubouterine implantation was described in the late 19th century¹. The first successful tubouterine implantation resulting in pregnancy was described by Turck in 1909². Since surgical correction of proximal tubal occlusion by tubouterine implantation was first described, other small case series have followed and have demonstrated conception rates ranging from 13.5% to 56%³. The risks of tubouterine implantation have also been described and were discussed in a study meta-analysis as recently as 1984⁴.

Despite the long history of tubouterine implantation, the American Society for Reproductive Medicine has not looked favorably upon tubouterine implantation as an effective treatment for proximal tubal occlusion. In committee opinion the ASRM states microsurgery can be attempted for proximal tubal occlusion by those skilled in microsurgery but the very next sentence states, “Tubal implantation has been relegated to historical interest only, as it has been associated with very low success rates and risks of cornual rupture in pregnancy⁵.”

We have found tubouterine implantation can be provided on an outpatient basis, safely, and with success. We have discovered a ‘historical’ procedure now has a new  indication for use in correcting a more ‘modern’ form of tubal sterilization.

Tubouterine implantation and

Essure sterilization reversal

The FDA approved Essure sterilization in 2002. We began to receive sporadic inquires regarding surgical reversal of Essure in 2008. Since hysteroscopic sterilization works by causing proximal blockage of the fallopian tube it was only natural that we utilized tubouterine implantation to correct this proximal tubal blockage.

We performed our first successful reversal of hysteroscopic sterilization reversal (Adiana sterilization) in early 2009 and our first successful reversal of Essure in late 2009. Our first Adiana reversal patient quickly became pregnant, experienced an early miscarriage, and then quickly became pregnant a second time. She had an uncomplicated pregnancy and delivered by cesarean delivery. In 2011 we published a case report about this successful pregnancy after tubouterine implantation for reversal of Adiana sterilization⁶. In 2012, we published a case report on two successful pregnancies after tubouterine implantation after reversal of Essure sterilization⁷.

Risks of tubouterine implantation

We have had good success performing tubouterine implantation as an outpatient procedure. Our immediate complication rate during surgery requiring hospital transfer has been less than 1%. No patient has required a blood transfusion. Our delayed complication rate is less than 5% and is defined as any surgical site infection or unanticipated doctors visit within the first 30 days of surgery.

Although the most likely significant risk of tubouterine implantation is uterine rupture, only one (1) patient over seven (7) years has reported a uterine rupture. This uterine rupture occurred at 36 weeks gestation and was diagnosed at the time of cesarean without any significant maternal or fetal complications. Another patient was transfused for heavy vaginal bleeding after cesarean delivery but no additional treatment was required.

More information regarding: Risks of uterine rupture and recommended route of delivery

Pregnancy statistics after tubouterine implantation

From January 2008 to May 2014, we performed one hundred and forty-three (143) tubal surgeries to correct either Essure or Adiana sterilization. Of the 143 women who sought treatment from our center, ninety-seven women (97) sought Essure sterilization reversal to become pregnant. The pregnancy rate after bilateral tubouterine implantation was 40% in this group of patients.

For more detailed information on our Essure reversal statistics: Essure reversal pregnancy statistics

IVF: An alternative to tubouterine implantation

In-vitro fertilization is an alternative to surgical reversal of Essure. In general the chance of pregnancy after a single cycle of in-vitro fertilization is 35.8%⁸.

We have had several patients who have had Essure reversal after failed in-vitro fertilization. Some of these patients were discovered to have intracavitary projection of the Essure micro-insert devices. We have observed patients who have more than the manufacturer’s recommendation of coils projecting into the uterine cavity may be more likely to complain of cramping and increased menstrual flow after Essure sterilization. It may be reasonable to consider a diagnostic hysteroscopy in patients with Essure prior to starting an IVF cycle. If the devices are found to project into the uterine cavity then device removal should be considered before attempting IVF.

There is no data to suggest what the success rate of IVF is when the Essure coils are allowed to remain; however, several case reports do exist of successful IVF with Essure coils in situ.^9,10 Limited  studies exists suggesting minimal risks to pregnancy in women who become pregnant after Essure failure or those who intentionally become pregnant with IVF.^11,12

References

1. Ries E. Plastic operation on the fallopian tubes. Am J Surg Gynecology 1899;11:180.
2. Turck RC. Hysterosalpingostomy. NY Med J 1909; 89:1193.
3. Diamond E. A comparison of gross and microsurgical techniques for repair of cornual occlusion in infertility: A retrospective study, 1968-1978. Fertil Steril 1979; 32:370.
4. Jewelewicz R, Shortle B. Uterine rupture following tubal reimplantation. Review of the literature and report of three additional cases. Obstet and Gynecol Survey 1984; 39(7):407-415.
5. Committee opinion: role of tubal surgery in the era of assisted reproductive technology. American Society for Reproductive Medicine. Fertility Sterility 2012;97:539-45.
6. Monteith CW, Berger GS. Normal pregnancy after outpatient tubouterine implantation in patient with Adiana sterilization. Fertil Steril. 2011 Jul;96(1):e45-6.
7. Monteith CW, Berger GS. Successful pregnancies after removal of intratubal microinserts. Obstet Gynecol. 2012 Feb;119(2 Pt 2):470-2.
8. Assisted Reproductive Technology Fertility Clinic Success Rates Report. Centers for Disease Control and Prevention 2011.
9. Kerin JF, Cattanach S. Successful pregnancy outcome with the use of in vitro fertilization after Essure hysteroscopic sterilization. Fertility Sterility 2007; May 87(5) 1212.
10. Galen DI, Khan N, Richter KS. Essure multicenter off-label treatment for hydrosalpinx before in vitro fertilization. J Minim Invasive Gynecol 2011; May-June;18(3):338-42.
11. Veersema S et al. Outcomes of Pregnancies in Women with Hysteroscopically Placed Micro-Inserts In Situ. J. Minim Invasive Gynecol 2013; Oct Suppl.
12. Arora P, Arora R, Cahill D. Essure for management of hydrosalpinx prior to in vitro fertilisation- a systematic review and pooled analysis. BJOG 2014; Jan 3.