What is the next step for imaging if the Essure (non-surgical permanent birth control device) device is not visible on ultrasound?

Imaging for Essure Device Not Visible on Ultrasound

When the Essure device is not visible on ultrasound, hysterosalpingography (HSG) should be performed as the next imaging step to confirm proper placement and tubal occlusion.

Understanding Essure Device Imaging

The Essure device is a permanent birth control implant placed hysteroscopically into the fallopian tubes, where it causes occlusion through fibrosis. Proper imaging is crucial for confirming:

1. Correct positioning within the fallopian tubes
2. Successful tubal occlusion
3. Absence of complications (perforation, migration, or expulsion)

Imaging Algorithm for Essure Device Assessment

Initial Imaging

• Combined transvaginal and transabdominal ultrasound is the recommended first-line imaging approach 1
• Ultrasound allows visualization of the relationship between the device and uterine cavity without radiation exposure
• The devices should appear as echogenic coil-like structures within each uterine cornua extending into the proximal fallopian tubes 2

When Ultrasound Is Non-Diagnostic (Device Not Visible)

1. Hysterosalpingography (HSG)

   • Gold standard for confirming tubal occlusion and proper device placement 3
   • Can definitively assess device function by demonstrating tubal blockage
   • Allows visualization of potential complications including perforation or migration

2. Three-Dimensional Ultrasound (if available)

   • May provide better visualization than standard 2D ultrasound
   • Particularly useful for evaluating the curvature and route of the implant 4
   • Can detect subtle displacements not visible on standard ultrasound

3. X-ray

   • Can confirm presence of the device but cannot reliably distinguish between properly positioned and malpositioned devices 1
   • Limited in determining precise location relative to soft tissue structures

4. CT Imaging

   • Consider if perforation with migration is suspected
   • Particularly useful if migration to peritoneal cavity is suspected

Evidence Supporting HSG After Non-Diagnostic Ultrasound

Research shows that when ultrasound cannot visualize the Essure device, HSG is the appropriate next step:

• In a study of 610 women with Essure placement, 15% required HSG after ultrasound follow-up, including 34 cases where ultrasound was non-diagnostic 5
• HSG is specifically designed to evaluate tubal patency and is therefore ideal for confirming proper Essure function 3

Common Pitfalls in Essure Imaging

• Vascular intravasation during HSG is the most common cause of diagnostic error 3
• Failure to evaluate device curvature on ultrasound may miss tubal perforation 4
• Relying solely on X-ray can miss malposition as it cannot reliably distinguish between properly positioned and malpositioned devices 1

Clinical Implications

Proper imaging follow-up is essential as malpositioned devices can lead to:

• Decreased contraceptive efficacy
• Perforation
• Migration (toward uterine or peritoneal cavity)
• Need for device removal and replacement

By following this imaging algorithm when an Essure device is not visible on ultrasound, clinicians can ensure proper device placement and function, ultimately safeguarding patient safety and contraceptive efficacy.