Imaging of Mechanical Tubal Occlusion Devices and Potential Complications

Abstract

The increasing use of permanent mechanical contraceptive devices has placed growing demands on radiologists. Hysteroscopically placed tubal occlusion devices, in particular, must be evaluated promptly and carefully to verify that they are in a satisfactory location and are functioning effectively. Hysterosalpingography, radiography, ultrasonography, computed tomography, and magnetic resonance imaging all may be useful for this purpose; however, the acquisition and interpretation of images of these devices can be challenging and requires specific knowledge. Verification of tubal occlusion with a hysteroscopically placed device depends heavily on the adequacy of cornual distention with the contrast medium at hysterosalpingography. Some complications of coil (Essure device) placement, such as tubal perforation and device migration, may be clinically occult and their imaging appearances subtle; a high degree of suspicion is needed to detect them at postprocedural imaging. The position of another tubal occlusion device, a radiolucent silicone matrix (Adiana device), is not directly depicted at imaging with x-rays. By contrast, laparoscopically placed locking tubal clips are well depicted at radiography; however, their dislodgement and migration are seldom symptomatic and thus unlikely to be discovered in time to avert pregnancy. The use of any tubal occlusion device is associated with low albeit finite risks of unwanted intrauterine pregnancy, ectopic pregnancy, tubal and uterine perforation, and device migration into the peritoneal cavity. Results of multiple trials show that a substantial percentage of such complications occurred because of image misinterpretation and consequent patient reliance on tubal occlusion alone for contraception. Accurate description and classification of abnormalities in device position or function seen at imaging performed postprocedurally or for other clinical indications will enhance the value of radiologists' contributions to patient care.

Utility of Three-Dimensional Ultrasonography to Assess the Position of Essure Tubal Occlusion Device and Its Complications

“…HSG is a method designed to evaluate tubal patency in sterile patients and can lead to wrong results if the pressure of the radiocontrast is too high or too low or under tubal spasm or intravasation [8,18,19] . There is even a case report in which a patient expulsed the device after HSG demonstrating bilateral tubal occlusion, and posterior histological analysis showed no fibrosis in one of the tubes [20] .…”

Asymptomatic Serosalized Essure Microinsert in the Distal Ileum

“…Perforation of the uterus or fallopian tube at the time of microinsert placement occurs in up to ϳ2% of cases. 11 Possible causes of perforation include poor visualization during device placement, tubal spasm, or uterine and tubal abnormalities. 5,11 In these settings the microinsert is less likely to track along the fallopian tube, thereby increasing the likelihood for perforation.…”

“…11 Possible causes of perforation include poor visualization during device placement, tubal spasm, or uterine and tubal abnormalities. 5,11 In these settings the microinsert is less likely to track along the fallopian tube, thereby increasing the likelihood for perforation. 6,11 Migration of microinserts after placement is extremely rare, with an estimated incidence of 0.1%.…”

“…5,11 In these settings the microinsert is less likely to track along the fallopian tube, thereby increasing the likelihood for perforation. 6,11 Migration of microinserts after placement is extremely rare, with an estimated incidence of 0.1%. 11 Although current data indicate that long-term adverse events are not associated with microinsert perforation and migration, microinsert-induced bowel perforation and bowel obstruction have been described in the medical literature.…”

“…6,11 Migration of microinserts after placement is extremely rare, with an estimated incidence of 0.1%. 11 Although current data indicate that long-term adverse events are not associated with microinsert perforation and migration, microinsert-induced bowel perforation and bowel obstruction have been described in the medical literature. 4 -6 Mantel et al 5 recently published a case of small-bowel obstruction and perforation occurring 1 month after Essure microinsert placement.…”