Real World Effectiveness and Safety of Hysteroscopic (Essure®) Compared to Laparoscopic Sterilization

More than 345,000 U.S. women undergo either tubal ligation ("getting her tubes tied") or Essure procedures each year to permanently avoid pregnancy. Both prevent pregnancy by blocking women's Fallopian tubes but neither are 100% effective. Both can have complications, but not enough is known to help women make an informed choice between the two.

Essure is popular because it can be performed without anesthesia in a doctor's office and women can return to work the next day. However, patients have reported that the Essure procedure was unexpectedly painful. Also, women need to use other contraceptives for 3 months and then return for testing, to make sure their tubes are blocked and will prevent pregnancy. Not all women return for this test and some may get pregnant before realizing their Essure didn't work.

Essure was approved by the Food and Drug Administration (FDA) in 2002, but no studies ever compared it to tubal ligation. By 2015, over 9,000 women reported serious complications to the FDA. Women who were unhappy with Essure found each other online and created a Facebook "Essure Problems" support group that now has over 31,000 members. After an FDA Advisory Board expressed concerns about Essure's risks, in 2016 the FDA required stronger warnings about complications and announced that "more rigorous research" was needed, demanding Essure's maker conduct a new study comparing the benefits and risks of Essure to tubal ligation. Unfortunately, that study will not be finished before September 2023.

To provide answers as rapidly as possible for women considering sterilization, we will analyze data from the medical records of thousands of women with sterilization procedures funded by California's Medicaid. As poor women and women of color have different experiences with healthcare, and they more often choose sterilization, comparing these women's experiences with Essure and tubal ligation is very important. We will compare the safety and effectiveness of the 2 sterilization procedures to answer:

• How many women got pregnant afterwards?
• How many operations did each woman need to become infertile?
• Which complications did women have (i.e. chronic pain, depression)? We will also check whether certain women (such as certain age groups or those with diabetes) were most likely to have problems after either procedure.

Study Overview

• Status: Completed
• Conditions: Contraception; Sterility, Female; Contraceptive Device; Complications
• Intervention / Treatment: Device: Essure; Procedure: Laparoscopic sterilization; Device: Intrauterine Device (IUD)

Detailed Description

Study Aims:

Aim 1. To compare the real world effectiveness of hysteroscopic sterilization, laparoscopic sterilization and intrauterine devices (IUDs) by calculating:

1. Pregnancy rates at 3, 6, 12, 24, 36, 48, and 60 months post-procedure, indicating sterilization failure.
2. Patient's ability to rely on sterilization after hysteroscopic sterilization (blocked tubes on hysterosalpingogram) compared to laparoscopic sterilization and IUDs at 3, 6, 12, 24, 36, 48, and 60 months post-procedure, indicating concern of sterilization failure.

Aim 2. To compare safety and complications after hysteroscopic sterilization laparoscopic sterilization, and IUD placement by:

1. Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement at 3, 6, 12, 24, 36, 48, and 60 months post-procedure.
2. Evaluating other outcomes suggested by patient partners, including additional surgeries due to complications, chronic pain, and/or depression, by measuring claims for narcotic prescriptions, and antidepressants at 3, 6, 12, 24, 36, 48, 60 months post-procedure (hysteroscopic sterilization, laparoscopic sterilization, or IUD placement).
3. Identify sociodemographic and pre-sterilization clinical variables which may predict complications following hysteroscopic sterilization compared to laparoscopic sterilization and to IUDs.

• Study Type: Observational
• Enrollment (Actual): 89203

Contacts and Locations

Study Locations

• United States
  • Connecticut
    • New Haven, Connecticut, United States, 06510
      • Yale University School of Medicine

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 50 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

• Sampling Method: Non-Probability Sample

Study Population

We will use linked data from Centers for Medicare and Medicaid Services (CMS) Research Data Assistance Center (ResDAC) including research identifiable files (RIF) containing Medicaid records, known as the Medicaid Analytic Extract (MAX) files to identify women who have undergone hysteroscopic or laparoscopic sterilization procedures or IUD placement. The MAX files contain claims, encounters, and eligibility information on recipients of California's Medicaid program (Medi-Cal).

Description

Inclusion Criteria:

• Women aged 18-50 years at the time of sterilization procedure
• Claims indicating hysteroscopic or laparoscopic sterilization procedures or IUD placement

Exclusion Criteria:

• Active cancer
• Any conditions that would have excluded the patient for hysteroscopic sterilization
• Any conditions that would have excluded the patient for laparoscopic sterilization

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Retrospective

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Essure Hysteroscopic Sterilization; Women who have undergone Essure hysteroscopic sterilization	Device: Essure; Essure hysteroscopic sterilization
Laparoscopic Sterilization; Women who have undergone laparoscopic sterilization	Procedure: Laparoscopic sterilization; Laparoscopic sterilization via electrocautery, ring, or clip.
Intrauterine device (IUD) placement; Women who have undergone IUD placement	Device: Intrauterine Device (IUD); Intrauterine Device (IUD)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 3 months post-procedure
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 6 months post-procedure
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 12 months post-procedure
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 24 months post-procedure
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 36 months post-procedure
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 48 months post-procedure
Effectiveness of hysteroscopic compared to laparoscopic sterilization and IUD placement (Aim 1a)	Pregnancy after sterilization or IUD placement, indicating failure	Pregnancy rates at 60 months post-procedure

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	3 months post-procedure
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	6 months post-procedure
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	12 months post-procedure
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	24 months post-procedure
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	36 months post-procedure
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	48 months post-procedure
Blocked fallopian tubes on post-procedure hysterosalpingogram test (Aim 1b)	Ability to rely on sterilization after hysteroscopic sterilization (assessed by having blocked tubes on post-procedure hysterosalpingogram test) compared to laparoscopic sterilization and IUDs	60 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	3 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	6 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	12 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	24 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	36 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	48 months post-procedure
Reoperation to achieve sterilization or reinsertion to achieve IUD placement	Evaluating rates of reoperation to achieve sterilization or reinsertion to achieve IUD placement	60 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	3 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	6 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	12 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	24 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	36 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	48 months post-procedure
Need for subsequent surgery to remove foreign body, remove fallopian tube(s) (salpingectomy), or uterus (hysterectomy)	Need for surgical procedure after hysteroscopic or laparoscopic sterilization or IUD placement as assessed by surgery to remove foreign body, salpingectomy, or hysterectomy	60 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	3 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	6 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	12 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	24 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	36 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	48 months post-procedure
Number of participants with new onset chronic pain as assessed by new prescriptions for narcotics	New prescription for narcotics after hysteroscopic compared to laparoscopic sterilization and IUD placement	60 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	3 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	6 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	12 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	24 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	36 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	48 months post-procedure
Number of participants with new onset depression as assessed by new prescriptions for antidepressants	New prescription for anti-depressant medication after hysteroscopic compared to laparoscopic sterilization and IUD placement	60 months post-procedure
Pre-procedure clinical variables associated with procedural complications	Identify sociodemographic and pre-procedure clinical variables which may predict complications following hysteroscopic sterilization compared to laparoscopic sterilization and IUD placement	Up to 1-year pre-procedure

Collaborators and Investigators

• Sponsor: Yale University
• Collaborators: Patient-Centered Outcomes Research Institute; University of California, Davis; Food and Drug Administration (FDA); National Center for Health Research
• Investigators: Principal Investigator: Aileen Gariepy, MD, Yale University

Publications and helpful links

General Publications

• Gariepy AM, Lewis C, Zuckerman D, Tancredi DJ, Murphy E, McDonald-Mosley R, Sonalkar S, Hathaway M, Nunez-Eddy C, Schwarz EB. Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study. Fertil Steril. 2022 Jun;117(6):1322-1331. doi: 10.1016/j.fertnstert.2022.03.001. Epub 2022 Apr 12.
• Schwarz EB, Lewis CA, Dove MS, Murphy E, Zuckerman D, Nunez-Eddy C, Tancredi DJ, McDonald-Mosley R, Sonalkar S, Hathaway M, Gariepy AM. Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation. J Gen Intern Med. 2022 Feb 23:1-8. doi: 10.1007/s11606-022-07433-4. Online ahead of print.
• Gariepy AM, Lewis C, Zuckerman D, Tancredi DJ, Murphy E, McDonald-Mosley R, Sonalkar S, Hathaway M, Nunez-Eddy C, Schwarz EB. Patient-Centered Safety Outcomes After Hysteroscopic Compared With Laparoscopic Sterilization. Obstet Gynecol. 2022 Mar 1;139(3):423-432. doi: 10.1097/AOG.0000000000004690.

Helpful Links

• This work was (partially) supported through a Patient-Centered Outcomes Research Institute (PCORI) Award 1609-36359

Study record dates

Study Major Dates

• Study Start (Actual): September 30, 2018
• Primary Completion (Actual): July 31, 2021
• Study Completion (Actual): July 31, 2021

Study Registration Dates

• First Submitted: January 29, 2018
• First Submitted That Met QC Criteria: February 12, 2018
• First Posted (Actual): February 20, 2018

Study Record Updates

• Last Update Posted (Actual): November 3, 2021
• Last Update Submitted That Met QC Criteria: November 1, 2021
• Last Verified: November 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Infertility; Infertility, Female
• Other Study ID Numbers: 2000020734; 1U01FD005938-01 (U.S. FDA Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes
• product manufactured in and exported from the U.S.: No