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Subject: Hysteroscopic Female Sterilization with Microinsert (Essure)
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Urine pregnancy test.
Premedication with a nonsteroidal anti-inflammatory drug (NSAID) of the provider’s choice (suppositories, oral medicine, or intramuscular injection).
Atropine (0.5 to 1.0 mg) can be given intravenously, subcutaneously, or intramuscularly. Initial single doses in adults vary from around 0.5 to 1 mg for bradycardia associated with vagal reaction.
Standard gynecological equipment tray including tenaculum and dilators.
Weighted speculum, Graves speculum, or Graves speculum with open side.
Single-tooth tenaculum (two).
Gimpelson tenaculum for patulous cervix or endoloop for patulous cervix.
Sterile gauze, 2 × 2 inches or 4 × 4 inches.
Operating hysteroscope sheath with 5-French or larger channel.
30-degree hysteroscope lens (12-degree or 0-degree will not work with lateral tubes).
Tubing and drapes for hysteroscope system being used.
Normal saline, 1- or 3-L bags warmed to reduce tubal spasm.
Local anesthetic for paracervical block (bupivacaine or lidocaine).
Control-top syringe and 22-g spinal needle.
Essure systems, two minimum. Additional units should be available in case of malfunction or inadvertent contamination.
Patient ID card supplied with Essure package.
Patient who desires to end fertility permanently (must be older than 21 in most states)
Younger than 45 years of age, although this is a personal choice of patient and physician
Inability to tolerate general anesthesia
Medical conditions that make pregnancy and/or general anesthetics dangerous
Previous abdominal surgeries that increase the risk of complications
Willing to use another form of birth control for 3 months and undergo an HSG to confirm placement and tubal occlusion
Unsure about desire to end fertility
Patients in whom only one microinsert can be placed
Patients with previous tubal ligation
Patients with unicornuate uterus
Known or suspected pregnancy
Pregnancy less than 6 weeks prior to placement
Active or recent pelvic infection
Known allergy to contrast media
Known allergy to nickel confirmed by skin test
Inability to follow-up or refusal to have confirmatory HSG
Immunosuppressive therapy with systemic corticosteroids, chemotherapy, or other agents such as tumor necrosis factor (TNF) blockers (relative contraindication, as the therapy is expected to negatively affect tissue response)
PEARL: Anticoagulated patients should be managed with the patient’s primary provider, depending on the anticoagulant and the underlying medical disorder.
PEARL: Routine catheterization of the bladder is not required but may be necessary if there has been a long wait or the patient has received excessive intravenous fluids.
PITFALL: The key to successful local anesthetic is placing it properly and waiting for it to work prior to stimulating the surgical site. Begin assembling the other equipment only after placing the anesthetic. It takes about 3 minutes to assemble the hysteroscope and prepare for the next portion of the procedure, just about the time needed for local anesthetic to be effective.
PITFALL: Cold solution increases pain and tubal spasm. This can be greatly reduced by heating the solution to body temperature. Care must be taken not to make the solution hot enough to cause a burn.
PITFALL: The uterine sound is not necessary and indeed increases the risk of perforation. It is not possible to continue this procedure if perforation is diagnosed.
PITFALL: It is important not to open the Essure microinsert package until the endometrial cavity is visualized and both tubal ostia confirmed. If both tubal ostia cannot be seen or the endometrium is too thick, then the procedure should be cancelled and possibly rescheduled.
PITFALL: Note which device is being used. The following steps are for the new ESS305 system with the purple handle, not for the previous version with the white handle.
PEARL: The valve in the introducer prevents fluid from splashing back. The fluid no longer needs to be turned off during catheter insertion.
PITFALL: Note that the tip of the Essure is curved. Do not attempt to straighten the tip, because the curve is important for guiding it into the tubal ostia. The dominant hand should manipulate the catheter and the nondominant hand should hold the hysteroscope.
PEARL: Consider starting with the right tubal ostia. This makes it easier to keep track of which side was done first and to find the opposite side.
PITFALL: If the catheter flexes while advancing, moving the hysteroscope closer to the ostium will make the catheter act stiffer.
PEARL: To place the catheter in lateral tubes, it is necessary to turn 30 degrees away from the ostium; that is, turn the lightpost toward the ostium, not away from it. This is counterintuitive to most hysteroscopists, but it is necessary for successful placement.
Nausea and vomiting
Bleeding or spotting
Expulsion or migration of microinsert