The Connect Dialogues
The Connect Dialogues

In this issue:

Sterilization into
Everyday Practice

Sterilization in
Residency Training
and Practice



Incorporating Hysteroscopic Sterilization into Everyday Practice
Deborah Bartz, MD, MPH
Brigham & Women’s Hospital | Boston, MA

I am thrilled with the expansion of content on hysteroscopic sterilization in the ACOG Practice Bulletin 133, “Benefits and Risks of Sterilization,” February 2013! Like many gynecologists, I rely heavily on ACOG publications for their thorough, accurate reporting of the scientific literature as well as their patient-targeted educational resources, which provide an important means of counseling my patients. Given the global clinical experience published on hysteroscopic sterilization over the last decade that has been incorporated into the ACOG resources, these updated documents are invaluable to my busy practice.

Best practices in female sterilization is a very relevant topic for my patients and for many women throughout the United States: approximately 17% of women using any contraception in 2008 relied on female sterilization.1 Roughly 50% of female sterilization procedures are performed as interval procedures outside of the setting of pregnancy.2

Hysteroscopic Sterilization Advantages
Hysteroscopic sterilization has several advantages over conventional laparoscopic sterilization while still affording women the same—and potentially superior—efficacy in permanent contraception. There is decreased procedure risk and time, less need for anesthesia, reduced use of medical resources, and the possibility of lower costs for anesthesia and surgical complications with hysteroscopic sterilization.3,4 The ease and convenience of this procedure for practitioner and patient allows for the flexibility to perform hysteroscopic sterilization in multiple clinic settings, including one’s office. Lastly, required confirmatory testing with a hysterosalpingogram (HSG) following hysteroscopic sterilization provides comfort of procedure success for the patient as well as the physician. The combined advantages versus other options have resulted in high rates of patient satisfaction reported in multiple patient populations studied.5,6,7 ACOG Practice Bulletin 133 presents updated content on all sterilization methods within the context of the reassuring research done over the last decade since hysteroscopic sterilization became available on the US market.

Patient Benefits and Preference
The updated review of the literature contained within the Practice Bulletin offers physicians a critical resource for advising patients on all birth control options, including sterilization methods. Additionally, the passing of the US Affordable Care Act (ACA) allows all sterilization procedures to be fully covered, making price far less of a factor when pitted against more urgent concerns.8 Procedure success and the patient’s short- and long-term satisfaction are all dependent on optimal candidate selection. The recommendations within the Practice Bulletin clearly outline the critical components of decision-making surrounding sterilization, including both medical and social considerations.

My patients appreciate this review of all sterilization methods compared with their other contraceptive options, including laparoscopic sterilization and long-acting reversible contraception. Recently, Hector Chapa, MD, and his colleagues published the first US study highlighting patient preference of interval sterilization methods and found that 94 of 100 women chose hysteroscopic sterilization when presented with the facts on both interval sterilization methods at a preoperative appointment.7 Indeed, the data on hysteroscopic sterilization are comforting for my patients and their partners.

Given improved patient safety and outcomes, the trend toward minimally invasive procedures, and medical cost containment, the pluses of hysteroscopic sterilization for the patient and the physician demonstrated over the last decade of use are highly convincing. For these reasons, this form of female sterilization has become the gold standard for permanent birth control in my practice and in many others across the nation. In conclusion, ACOG’s Practice Bulletin 133 has allowed me to communicate these benefits with my colleagues, residents, students, and patients.

1. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat 23. 2010 Aug(29): 1-44.

2.MacKay AP, Kieke BA Jr., Koonin LM, Beattie K. Tubal sterilization in the United States, 1994-1996. Fam Plann Perspect. 2001;33(4):161-165.

3. Povedano B, Arjona JE, Velasco E, Monserrat JA, Lorente J, Castelo-Branco C. Complication of hysteroscopic Essure sterilisation: report on 4306 procedures performed in a single centre. BJOG. 2012; 119(7):795-799.

4. Kraemer DF, Yen B-Y, Nichols M. An economic comparison of female sterilization of hysteroscopic tubal occlusion with laparoscopic bilateral tubal ligation. Contraception. 2009;80(3):254-260.

5.Arjona JE, Mino M, Cordon J, Povedano B, Pelegrin B, Castelo-Branco C. Satisfaction and tolerance with office hysteroscopic tubal sterilization. Fertil Steril.2008;90(4):1182-1186.

6.Levie M, Weiss G, Kaiser B, Daif J, Chudnoff SG. Analysis of pain and satisfaction with office-based hysteroscopic sterilization. Fertil Steril. 2010;94(4):1189-1194.

7.Chapa HO, Venegas G Preprocedure patient preferences and attitudes toward permanent contraceptive options. Patient Prefer Adherence. 2012;6:331-336.

8.Institute of Medicine. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC:
The National Academies Press; 2011.

Incorporating Hysteroscopic Sterilization in Residency Training and Practice
Beth Rackow, MD
Columbia University | New York, NY

Training as a women’s health practitioner should incorporate the expertise to counsel women regarding all contraceptive options such as reversible, long-acting reversible, and permanent methods. Important components of contraceptive counseling include an unbiased discussion of use, safety, efficacy, benefits and risks. Since female sterilization is a leading contraceptive choice for women who have completed childbearing,1 as their health care practitioners, we must familiarize ourselves with all permanent birth control options in order to best educate each patient about available methods.

The recently published ACOG Practice Bulletin 133 on sterilization provides an updated review of female sterilization options including new content on hysteroscopic sterilization, and is a valuable resource for practitioners.1 The 2013 Bulletin reviews techniques as well as efficacy and safety data for postpartum, postabortion, laparoscopic and hysteroscopic sterilization methods. The authors provide guidelines for comprehensive counseling, including “surgical technique, efficacy, safety, potential complications, and alternatives to female sterilization.”1

Evidence-Based Practice
Over the past 10 years, hysteroscopic sterilization has emerged as a safe, low-risk, and highly effective option for permanent contraception. Compared with laparoscopic interval sterilization, advantages of the hysteroscopic approach include the avoidance of entry into the peritoneal cavity, the ability to perform the procedure without general anesthesia, and an established lower rate of complications.2 Furthermore, women benefit from the lack of an abdominal incision, resulting in a quick recovery and return to daily activities. Importantly, hysteroscopic sterilization can be safely performed in the office with minimal analgesia. Similar to a vasectomy, reliable contraception is required for three months postprocedure until a visual confirmation test is performed. This demonstration of satisfactory micro-insert placement and effective tubal occlusion reassures the woman that she can trust this permanent contraceptive method. Hysteroscopic sterilization has a high rate of efficacy: 99.83% at 5-year follow-up after successful bilateral placement of inserts (per product labeling); this is an improvement over the 1.31% failure rate of all tubal sterilization techniques and the failure rate of laparoscopic bipolar tubal sterilization of 1.65% at 5 years postprocedure and 2.48% at 10 years postprocedure.3 Therefore, the ACOG Practice Bulletin states that hysteroscopic sterilization is considered to have “at least equal if not superior efficacy to tubal occlusion done by laparoscopy or minilaparotomy.”1

The Importance of Hysteroscopy Training
As we train the next generation of obstetricians and gynecologists, the acquisition of minimally invasive surgical skills is essential to provide the best care for women. Achieving competence in hysteroscopic procedures is critical because it is the standard method for diagnostic evaluation of the uterine cavity for conditions such as abnormal bleeding and for operative management of abnormalities such as endometrial polyps and submucosal uterine myomas.4 During training, as exposure to hysteroscopic procedures progresses from diagnostic to operative cases and from straight-forward to more challenging cases, residents should acquire the necessary skills that can be transferred to hysteroscopic sterilization. As an established procedure with demonstrated patient benefits, hysteroscopic sterilization needs to be a component of resident surgical education. Furthermore, as an increasing number of diagnostic and operative hysteroscopic procedures are being performed in the office, it is recommended that residents be exposed to office-based hysteroscopy including hysteroscopic sterilization procedures, so they can understand the technique, benefits and risks of office-based procedures.5 As a practicing physician, office hysteroscopy is an invaluable tool for me and my patients; and as a medical educator, it is my goal to train residents to be skilled hysteroscopic surgeons and to expose them to office hysteroscopy. With a solid foundation in hysteroscopy, established practitioners should have the skill set to learn office hysteroscopy and hysteroscopic sterilization while in practice. As with any medical procedure, appropriate patient selection and counseling, recognition of limitations in experience and skills, proper instruments, and a well-trained staff are critical to a successful procedure.5

With data to support equal or superior efficacy and safety of hysteroscopic sterilization compared with laparoscopic sterilization techniques, offering this procedure to appropriate patients represents a “best practice” in women’s health. A solid foundation in operative hysteroscopy should enable gynecologists to become proficient in hysteroscopic sterilization. Residency programs should also ensure that as part of hysteroscopic education, all residents receive training in this increasingly popular and advantageous form
of sterilization.

1. ACOG practice bulletin no. 133: benefits and risks of sterilization. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2013; 121(2 Pt 1):392-404.

2. Povedano B, Arjona JE, Velasco E, Monserrat JA, Lorente J, Castelo-Branco C. Complications of hysteroscopic Essure sterilisation: report on 4306 procedures performed in a single centre. BJOG. 2012;119(7):795-799.

3. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J; for the U.S. Collaborative Review of Sterilization Working Group. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174:1161-1168.

4. Van Dongen H, de Kroon CD, Jacobi CE, Trimbos JB, Jansen FW. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis. BJOG. 2007;114(6):664-675.

5. Siristatidis C, Chrelias C, Salamalekis G, Kassanos D. Office hysteroscopy: current trends and potential applications: a critical review. Arch Gynecol Obstet. 2010;282(4):383-388.

This educational newsletter is sponsored by Conceptus.

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