Combining NovaSure? endometrial ablation and Essure? hysteroscopic sterilization: a feasibility study to evaluate the confirmation tests

Since NovaSure? endometrial ablation (GEA) is not reliable as contraception, a reliable permanent contraceptive method which can be offered during the same operative session is often preferred by patients. We present a series of 24 patients treated by NovaSure? GEA followed by Essure? hysteroscopic sterilization at the same session. Bilateral placement of the micro-inserts after GEA was successful in all 24 patients. Confirmation by ultrasound and plain X-ray of the pelvis indicated a correct position in all 48 tubes. Routine follow-up by hysterosalpingography (HSG) to document bilateral tubal occlusion was only possible in 17/23 (74%) patients; these 34 tubes were blocked. In 6/23 (26%) patients, tubal occlusion could not be determined by HSG because of minimal filling of the uterine cavity with contrast medium. The latter was caused by severe uterine synechiae. All patients were satisfied with the result of GEA at 3 months; 19 women (83%) reported amenorrhea and the others, a strong reduction in menstrual blood loss. The combination of Essure? hysteroscopic sterilization and NovaSure? GEA is feasible and safe. However, after this combined approach the HSG as confirmation test is not always useful because of severe synechiae.     

Essure sterilization associated with endometrial ablation.

OBJECTIVE: To evaluate the feasibility and the outcome of Essure sterilization associated with different techniques of endometrial ablation. METHOD: Retrospective study conducted among 23 women with confirmed menometrorrhagia and with the desire for or the medical need for permanent tubal sterilization. Patients underwent combined hysteroscopic placement of Essure and hysteroscopic endometrial resection procedures: ThermaChoice (n=14), NovaSure (n=4), Hydrothermablator (n=2) and endometrial resection using monopolar energy (n=1), or bipolar energy (n=2). RESULTS: Fallopian tubes were successfully cannulated bilaterally in 87% of the cases (20/23). No adverse event was reported. Adequate bilateral occlusion was confirmed for all patients (20/20) by 3D ultrasound and pelvic X-ray at a 3-month follow-up. Furthermore, 85% of these patients were satisfied with the results of the procedure, all experiencing a significant reduction in menstrual blood loss (Higham blood loss score). CONCLUSION: Combining EA and hysteroscopic sterilization seems to be feasible and efficient in patients with menometrorrhagia.     

Analysis of Tubal Patency After Essure Placement

Study ObjectiveTo evaluate tubal patency after hysteroscopic sterilization using the Essure microinsert (Conceptus Inc, San Carlos, CA).DesignA retrospective longitudinal cohort study.Design ClassificationII-3.SettingPatients undergoing hysteroscopic sterilization in the outpatient clinic of a university-based hospital in Southeast Texas from July 2009 to November 2011.PatientsTwo hundred twenty-nine women (ages 21–44 yrs, 71% Hispanic) desiring sterilization with a history of regular menses, demonstrated prior fertility (≥1 live birth), and the ability to use an alternative contraceptive method for at least 90 days after coil placement were included. Twenty six patients in this cohort were excluded because of failure to perform a hysterosalpingogram (HSG), tubal perforation, severe dyspareunia, a history of ectopic pregnancy, tubal surgery, or cervical intraepithelial neoplasia.InterventionsNot applicable.Measurements and Main ResultsHSGs were assessed for microinsert location and tubal occlusion. Two hundred three patients were included for analysis. After the successful bilateral hysteroscopic placement of Essure microinserts in fallopian tubes, all patients returned for the first follow-up HSG a mean of 103 ± 38 days after the procedure. Patients with fallopian tube patency at the initial HSG returned for second and/or third HSGs as needed at 192 ± 45 and 291 ± 97 days, respectively. Correct device placement was confirmed in 100% of cases at the first HSG. The tubal patency rates at the 90-day and 180-day HSGs were 16.1% (95% confidence interval, 7.4%–31.7%) and 5.8% (95% CI, 1.2%–24.4%), respectively. These rates were estimated by the accelerated failure time model with log normal distribution and interval censored time to event. The 16.1% 90-day tubal patency rate is significantly different from the 8% rate reported by Cooper et al in the 2003 multicenter phase III pivotal trial (p <.001).ConclusionOur data indicate that hysteroscopic sterilization with Essure results in a higher initial tubal patency rate than previously reported. Multivariate analyses are needed to identify factors associated with an increased risk of postprocedure tubal patency.     

Essure Insert Expulsion After 3-Month Hysterosalpingogram Confirmation of Bilateral Tubal Occlusion and Bilateral Correct Placement: Case Report

Essure hysteroscopic sterilization is an effective permanent contraception option for women, with a 99.83% effectiveness rate. To date, more than 600,000 Essure procedures have been performed worldwide. This case report describes bilateral Essure insert placement, after which the left insert was subsequently expelled after hysterosalpingogram (HSG)–confirmed correct bilateral insert placement and bilateral tubal occlusion. Although insert expulsion has been reported before a 3-month post-procedure HSG, this is the first published report of expulsion after a confirmatory 3-month post-procedure HSG. Because there now exists documentation of Essure insert expulsion after a 3-month confirmatory HSG, physicians and patients should be informed of this rare occurrence. Further investigation into the causes of such an event is warranted.     

Hysteroscopic Sterilization Device Follow-Up Rate: Hysterosalpingogram Versus Transvaginal Ultrasound

Study Objective

To assess if follow-up confirmation testing 3 months after hysteroscopic sterilization with the Essure device (Bayer HealthCare Pharmaceuticals, Inc., Whippany, NJ) improved with recommendation for transvaginal ultrasound (TVUS) versus hysterosalpingogram (HSG).

Post-Essure hysterosalpingography compliance in a clinic population

STUDY OBJECTIVE: To determine the follow-up rate for post-Essure hysterosalpingography (HSG) in a non-study, general clinic population in an urban environment. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Eighty-three University Health Center (UHC) patients who underwent attempted placement of the Essure permanent birth control device at the ambulatory surgery center at Hutzel Women's Hospital from January 2003 through June 2007. INTERVENTION: Hysteroscopic placement of the Essure permanent birth control device. MEASUREMENTS AND MAIN RESULTS: Placement of the Essure permanent birth control device was attempted in 83 patients, of which 79 were successfully completed (95.2%). Of the 79 patients, 10 underwent post-Essure HSG (12.7%). HSG was performed 3 to 6 months after placement of the Essure device. Bilateral tubal occlusion was documented in all 10 patients. CONCLUSION: Despite preoperative and postoperative counseling, the follow-up rate for post-Essure HSG for this clinic population was only 12.7%. For those in whom HSG was performed, bilateral tubal occlusion was confirmed in all. Steps or approaches to promote compliance with postprocedural confirmation of tubal occlusion should be utilized to improve future follow-up rates.     

The role of Essure sterilization performed simultaneously with endometrial ablation

PURPOSE OF REVIEW: To review operative procedures, specific risks, complications and evaluation of efficacy of Essure tubal sterilization performed simultaneously with endometrial ablation. RECENT FINDINGS: Dysfunctional uterine bleeding is a significant health problem in premenopausal women. Endometrial ablation is an effective therapeutic option for the management of menorrhagia and an alternative to hysterectomy. Most women undergoing endometrial ablation are of reproductive age, and, because pregnancy after endometrial ablation could be complicated, many of these women require permanent birth control. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used and offers an hysteroscopic approach similar to endometrial ablation techniques. Combining these two procedures offers the advantage of performing the two procedures simultaneously, but inherent rules and technical procedures must be followed to avoid any kind of injury such as heat conduction, material injuries, specific complications and specific follow-up. SUMMARY: The combination of safety and efficacy of endometrial ablation and hysteroscopic sterilization makes a compelling argument for their concomitant use.     

Global Endometrial Ablation in the Presence of Essure? Microinserts

Abnormal uterine bleeding (AUB) affects 30% of women at some time during their reproductive years and is one of the most common reasons a woman sees a gynecologist. Many women are turning to endometrial ablation to manage their AUB. This article reviews the data relating to the available endometrial ablation techniques performed with hysteroscopic sterilization, and focuses on data from patients who had Essure® (Conceptus, San Carlos, CA) coils placed prior to performance of endometrial ablation. Reviewed specifically are data regarding safety and efficacy of these two procedures when combined. Data submitted to the US Food and Drug Administration for the three devices currently approved are reviewed, as well as all published case series. Articles included were selected based on a PubMed search for endometrial ablation (also using the brand names of the different techniques currently available), hysteroscopic sterilization, and Essure.Key words: Abnormal uterine bleeding, Endometrial ablation, Hysteroscopic sterilizationAbnormal uterine bleeding (AUB) affects 30% of women at some time during their reproductive years and is one of the most common reasons a woman sees a gynecologist.¹ AUB tends to occur more frequently as patients get older, and women typically present between the ages of 30 and 55 years with this problem. After appropriate evaluation, medical management is often the first line of treatment. However, many women are turning to endometrial ablation to manage their AUB. Patients are counseled to avoid pregnancy after endometrial ablation due to the increased risks for pregnancy after ablation. Problems such as premature rupture of membranes, preterm labor, intrauterine growth restriction, abnormal placentation, and higher cesarean delivery rates are reported.² Practitioners must offer a reliable contraceptive method after endometrial ablation has been performed.²There is a higher prevalence of women choosing permanent sterilization for their contraception as they age. According to the 2006–2008 National Survey of Family Growth, 28.2% of women aged 35 to 39 years and 39.1% of women aged 40 to 44 years use female sterilization as their choice of birth control.³ Ideally, women requiring endometrial ablation could benefit from concomitant procedures providing relief of their menorrhagia as well as permanent birth control. The transcervical approach of endometrial ablation and hysteroscopic sterilization makes the two methods well suited to be performed simultaneously, providing both menorrhagia relief and permanent sterilization. Furthermore, the second-generation endometrial ablation methods and hysteroscopic sterilization can both be performed in an office setting with local anesthetics and minimal anesthesia.Currently the NovaSure® (Hologic, Bedford, MA), hydrothermal ablation (HTA), and Gynecare ThermaChoice® (Ethicon, Somerville, NJ) are third-generation methods of global endometrial ablation (GEA) that are approved by the US Food and Drug Administration (FDA) for use with Essure® (Conceptus, San Carlos, CA) coils in situ. In consideration of performing a concomitant endometrial ablation with Essure coils in situ, several concerns regarding safety and efficacy need to be addressed.Hysteroscopic sterilization requires placement of a microinsert that spans the uterotubal junction. This coil is made up of stainless steel, nitinol, and polyethyl terpathalate material. Proper placement of the Essure coils requires 3 to 8 coils to be in the endometrial cavity,⁴ which puts the microinsert in direct or indirect contact with the ablation device. Some concerns that need to be evaluated include

1. Thermal and/or Electrical Conductivity
   • Given that the coils used in hysteroscopic sterilization are made out of metal, does the microinsert transmit the heat or conduct energy that is generated during endometrial ablation distally to the tube or outside the uterus?
   • What is the extent of damage that may occur due to this increase in temperature or energy transmission?
   • Most importantly, is the ability of the microinsert to yield tubal occlusion affected by its exposure to these conditions?
2. Tubal Occlusion Confirmation Testing
   • A confirmation of tubal occlusion prior to proceeding with endometrial ablation is currently recommended by the FDA.⁴ Although concomitant use of Gynecare ThermaChoice with Essure coils was granted by the FDA in 2006, this was rescinded after several patients had inadequate hysterosalpingogram (HSG) procedures due to Asherman syndrome. Therefore, how does ablation affect the ability to perform the confirmation test?
   • If the ability to perform HSG is compromised, are there alternatives to this confirmatory test that are acceptable?

     

Radiological control of Essure placements

Essure is a microinsert placed bilaterally into fallopian tube lumens under hysteroscopic visualization in patients seeking permanent contraception. Our multicenter clinical trial begun in 1998 required hysterosalpingography (HSG) be performed 3 months after placement to confirm tubal occlusion. The patency rate in satisfactorily placed devices was 4%. All of these underwent a repeat HSG 3–4 months later (due to a patency finding at the previous test). We present the results of our clinical use in patients out of the clinical trial. Of 78 insertions 65 (83.3%) were considered satisfactory, and the patients underwent pelvic radiography after 3 months. Only one patient had an abnormal radiograph, and an HSG was performed confirming bilateral tubal occlusion. In 12 patients (15.4%) the placement was considered unsatisfactory and underwent HSG. Ten confirmed bilateral tubal occlusion, and two had tubal patency. Therefore we repeated HSG 3 months later. We verified tubal occlusion in one patient and unilateral tubal patency in the other. In one patient with a satisfactory placement we performed an HSG that corroborated tubal occlusion. No pregnancies have been reported so far. Therefore we consider tubal occlusion successful in all the satisfactory microinsert placements (83.3%) after 3 months, performing only pelvic radiography. Additional HSG is required in the remaining 17% due to an unsatisfactory placement. Of these, 83% will be occluded after 3 months, increasing the rate to 91.6% after 6 months. These findings show that it is not necessary to conduct HSG when the bilateral placement is satisfactory and can be replaced by pelvic radiography at 3 months to confirm microinsert retention and location. HSG, with its unnecessary risks, costs, inconvenience and discomfort, can thus be avoided in many patients.     

Retrospective cost analysis comparing Essure hysteroscopic sterilization and laparoscopic bilateral tubal coagulation

STUDY OBJECTIVE: To compare the institutional cost of permanent female sterilization by Essure hysteroscopic sterilization and laparoscopic bilateral coagulation. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Midwestern academic medical center. PATIENTS: Women of reproductive age who elected for permanent contraception by the Essure method (n = 43) or by laparoscopic tubal coagulation (n = 44) during the time frame studied. INTERVENTIONS: Placement of the Essure inserts according to the manufacturer's instructions or laparoscopic tubal sterilization using bipolar forceps according to standard techniques of open or closed laparoscopy. MEASUREMENTS AND MAIN RESULTS: Cost-center data for the institutional cost of the procedure was abstracted for each patient included in the study. In addition, demographic data and procedural information were obtained and compared for the patient populations. The Essure system of hysteroscopic sterilization had a significantly decreased cost compared with laparoscopic tubal sterilization when both procedures were performed in an operating room setting. The decrease per patient in institutional cost was 180 dollars (p = .038). This included the cost of the confirmatory hysterosalpingogram 3 months after Essure placement and the cost of laparoscopic tubal occlusion by Filshie clip if the Essure micro-inserts could not be placed. The majority of the cost was related to hospital costs as opposed to physician costs. The Essure procedure had higher costs for disposable equipment (p <.0001), but this was offset by higher charges for operating room costs, which included the recovery room (p <.0001) and pharmacy costs (p <.0001) in the patients in the laparoscopy group. CONCLUSION: In our setting, the Essure hysteroscopic sterilization had significant cost savings compared with laparoscopic tubal sterilization (p = .038). We believe that our data represent the minimum of potential savings using this approach, and future developments will only increase the cost difference found in our study.     

Prospective analysis of office-based hysteroscopic sterilization

STUDY OBJECTIVES: To evaluate the efficacy of performing the Essure hysteroscopic sterilization in an office-based setting. DESIGN: Prospective, longitudinal analysis (Canadian Task Force classification II-3). SETTING: University out-patient office. PATIENTS: All patients undergoing permanent sterilization in our outpatient office who opted for hysteroscopic sterilization were included. INTERVENTIONS: Hysteroscopic placement of the Essure device in an office-based setting with only non-steroidal antiinflammatory drugs and paracervical block. MEASUREMENTS AND MAIN RESULTS: Multiple data points were collected on each patient including demographic data, specific procedural information, and 12-week hysterosalpingogram data. Most of our patients were Hispanic and had an average body mass index of 30.3. Average time to perform the procedure was 12.4 minutes, with the steepest improvement in the first 13 cases. Bilateral placement of the device was successful in 98 (96%) of 102 patients. Of these patients 92 have 12-week hysterosalpingography results (6 patients were lost to follow-up), with 90 (98%) showing bilateral tubal occlusion. There were no intraprocedural or postprocedural complications. CONCLUSION: In our institution and in our experience, office-hysteroscopic placement of the Essure device is a feasible and effective approach for permanent sterilization.     

Contrast infusion sonography in the post-Essure setting

STUDY OBJECTIVE: To compare contrast infusion sonogram (CIS) to hysterosalpingogram (HSG) for use as a 3-month confirmation test after Essure. DESIGN: Pilot study (Canadian Task Force classification II-2). SETTING: Healthy women in an academic multispecialty group. PATIENTS: Seventeen women desiring permanent sterilization who had had successful bilateral Essure placement within 12 weeks. INTERVENTION: Contrast infusion sonography was performed and immediately followed by an HSG at the same appointment, between 1 and 12 weeks after Essure placement. MEASUREMENTS AND MAIN RESULTS: To determine how well microinsert location and tubal status can be assessed with CIS, an adaptation of hysterosalpingo contrast sonography (HyCoSy), when compared with sequential HSG. Tubal occlusion rate within 4 to 8 weeks after Essure placement was also noted. All microinserts were readily identified with ultrasound, and location was accurately determined. In all patients (100%) with at least 1 tube patent on HSG, patency was also demonstrated on CIS by visualizing real-time flow in the tube or the presence of dye in the cul-de-sac or adnexa. There were no significant adverse events, and pain ratings were similar for both tests. The majority (88%) of patients felt strongly that they would prefer to have a 3-month confirmation test performed in the gynecologist's office rather than an unfamiliar radiologic facility. Tubal occlusion was noted on both CIS and HSG in 82% of patients before 12 weeks. CONCLUSION: Based on this pilot study with a small sample, CIS, an adaptation of HyCoSy, has comparable accuracy to HSG in the post-Essure setting. The safety, convenience, and comfort of an in-office test using ultrasound and a non-iodine-based dye would be a welcome alternative to HSG. There was also a high rate of bilateral fallopian tube occlusion noted on HSG at 4 weeks after Essure.     

Frequency of symptomatic cornual hematometra and postablation tubal sterilization syndrome after total rollerball endometrial ablation: a 10-year follow-up

OBJECTIVE: This study was undertaken to determine the frequency of symptomatic cornual hematometra and postablation tubal sterilization syndrome after total rollerball endometrial ablation and to describe methods for diagnosis, treatment, and prevention. STUDY DESIGN: Retrospective cases of 50 consecutive patients who received total rollerball endometrial ablation for dysfunctional uterine bleeding were followed up for 10 years. RESULTS: Symptomatic cornual hematometra or postablation tubal sterilization syndrome was diagnosed by ultrasound scanning and/or magnetic resonance imaging in 5 of 50 patients (10%) who had a total endometrial ablation. Two patients had cornual hematometra, and 3 patients had postablation tubal sterilization syndrome 4 months to 90 months after rollerball ablation. Subsequent gonadotropin-releasing hormone agonist treatment or hysteroscopic decompression of the hematometra was only partially successful, and recurrence of symptoms necessitated hysterectomy with salpingectomy. CONCLUSION: Uterine contracture, which obstructs bleeding from persistent cornual endometrium and leads to symptomatic cornual hematometra or postablation tubal sterilization syndrome, is not uncommon after total rollerball endometrial ablation, with an incidence of 10% in our series. Satisfactory treatment requires hysterectomy with salpingectomy, but modifications such as partial endometrial ablation can prevent these complications.     

Bilateral cornual abscess after endometrial ablation following Essure sterilization

Endometrial ablation is used extensively to treat dysfunctional bleeding. Since the introduction of Essure tubal sterilization, this permanent contraception method has been widely used. Both endometrial ablation and Essure sterilization are procedures reported to have only a few complications. We describe a serious infectious complication shortly after an endometrial ablation in a patient with Essure microinserts in situ. To our knowledge, this complication has not been reported before in patients with Essure microinserts in situ. We suggest administering prophylactic antibiotics before endometrial ablation in women with Essure microinserts in situ.     

Endometrial ablation with NovaSure GEA,a pilot study

OBJECTIVE: A prospective, single-arm, multicenter, controlled, observational pilot study to assess the safety and efficacy of the NovaSure Global Endometrial Ablation (NovaSure GEA) system in women with severe menorrhagia secondary to dysfunctional uterine bleeding (DUB). SETTING: University tertiary referring center and central hospital. PATIENTS: Forty-six premenopausal women aged 41.3 years with menorrhagia secondary to DUB unresponsive to medical therapy, who had completed childbearing, with non-distorted uterine cavities were included in the study. METHODS: Bleeding score was recorded before, 6 and 12 months after treatment. All patients received the treatment under intravenous sedation with para-cervical block and were treated with Nova Sure endometrial ablation for mean 94 s at the day surgery unit. RESULTS: No serious intraoperative complications were observed. Treatment time averaged 94 s. Forty-six patients have completed 6-months of follow-up and 45 patients completed the 12-months follow-up. 50% of the patients were amenorrheic at 6 months follow-up and 58% had complete cessation of uterine bleeding (amenorrhea) at 12 months follow-up. CONCLUSIONS: Preliminary results indicates that the NovaSure GEA System is an effective treatment for DUB, achieving 58% amenorrhea after 12 months.     

Post-ablation tubal sterilization syndrome following NovaSure endometrial ablation: two case reports

Endometrial ablation procedures are extensively used for the treatment of menorrhagia on premenopausal patients who failed medical therapy. The increasing popularity of safe, effective, less invasive, nonresectoscopic global endometrial ablation procedures could potentially increase the incidence of unusual adverse outcomes. Post-ablation tubal sterilization (PATSS) is one of these delayed complications, which could be challenging to diagnose. PATSS is a complication that potentially occurs following a global endometrial ablation in women with previous tubal sterilization. PATSS presents as cyclic pelvic pain caused by tubal distention from occult bleeding into the obstructed tubes. Review of the literature shows that majority of PATSS occurred after rollerball resection and ablation. We report two cases of PATSS after NovaSure? radiofrequency endometrial ablation.     

Hysteroscopic Sterilization in Patients with a Mirena Intrauterine Device: Transition from Extended Interval to Permanent Contraception

ObjectiveTo estimate the feasibility and elucidate the benefits of performing hysteroscopic sterilization in patients who have a Mirena intrauterine device (IUD) in place.DesignRetrospective case-controlled study with 3:1 ratio (Canadian Task Force Classification II-2).SettingProcedures were performed in an outpatient or office setting affiliated with an academic medical center. Hysterosalpingograms were obtained and interpreted jointly by an investigator and a radiologist using standard protocol.PatientsSubjects included all patients undergoing hysteroscopic sterilization July 2007 thru December 2008 with a Mirena IUD in place. Patients without an IUD served as a comparison group.InterventionsAll procedures were performed with a 4.2-mm Bettocchi continuous-flow hysteroscope with saline solution insufflation. Delivery catheters were passed through a 5F operative channel. Essure implants were positioned and released per standard protocol. IUD devices were removed after confirmation of bilateral tubal occlusion.Measurements & Main ResultsThere were 12 patients currently using a Mirena IUD for contraception who elected to undergo hysteroscopic sterilization. Procedures were performed in the usual manner. Chart review identified the most recently treated patients without an IUD in place matched for age and body mass index to study patients. Recorded details included age, body mass index, parity, procedure time, placement success, and tubal occlusion. There were no significant differences between the groups with respect to any metric except completion of the 3- month hysterosalpingogram.ConclusionHysteroscopic sterilization can be performed successfully with a Mirena IUD in place. Advantages include flexibility in timing of the procedure, assurance of contraception until confirmation of tubal occlusion, and increased likelihood of appropriate follow-up.     

Hysteroscopic sterilization in an immunosuppressed patient

Essure sterilization produces a local benign tissue response resulting in bilateral occlusion of the fallopian tubes 3 months after insertion. There is a precautionary warning about performing this procedure on immunosuppressed patients. We present a case of successful bilateral tubal occlusion with Essure in a patient with a history of kidney transplantation and receiving immunosuppressive medications.     

Trends in sterilization since the introduction of Essure hysteroscopic sterilization

Study ObjectiveTo investigate trends in sterilization in women at the Detroit Medical Center, Michigan (DMC), since the introduction of Essure hysteroscopic sterilization.DesignRetrospective study (Canadian Task Force classification II-2).SettingOutpatient surgery center and university teaching hospitals.PatientsWomen who underwent interval sterilization procedures at the DMC (Hutzel Women's Hospital, Sinai-Grace Hospital, and the Berry Center) and postpartum sterilization procedures at Hutzel Women's Hospital between January 1, 2002, and December 31, 2007.InterventionsPermanent sterilization procedures including minilaparotomy tubal ligation, laparoscopic sterilization, Essure hysteroscopic sterilization, and postpartum tubal ligation performed at the time of cesarean section or after vaginal delivery.Measurements and Main ResultsIn all, 5509 permanent sterilization procedures were performed in the 6 years between January 1, 2002, and December 31, 2007, at the DMC facilities analyzed: 2484 interval sterilization procedures at Hutzel Women's Hospital, Sinai-Grace Hospital, and the Berry Center, and 3025 postpartum tubal ligations at Hutzel Women's Hospital. From 2002 through 2007, the decrease in laparoscopic sterilizations from 97.9% to 48.5% of all interval sterilization procedures corresponded significantly with the increase in Essure hysteroscopic sterilizations from 0.0% to 51.3% (p <.001). Postpartum tubal ligations performed after vaginal delivery also decreased significantly during the study period from 7.9% to 3.3% of all vaginal deliveries (p <.001) while the percentage of tubal ligations performed at the time of cesarean section remained constant (p =.051).ConclusionAt the DMC facilities analyzed from January 1, 2002, through December 31, 2007, a significant decrease occurred in the percentage of laparoscopic sterilizations and postpartum tubal ligations performed after vaginal delivery. Of the interval sterilizations performed, the percentage of Essure hysteroscopic sterilizations increased significantly from 0.0% to 51.3% of all procedures. Since the approval of Essure hysteroscopic sterilization in November 2002, this minimally invasive method of hysteroscopic sterilization has increased in popularity at the DMC.