CASE 12632 Published on 03.05.2015

Mechanical tubal occlusion: imaging evaluation

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Baptista M, Montes Palma J, Matias M

Beja, Portugal
Email:martabaptista@gmail.com
Patient

40 years, female

Categories
Area of Interest Pelvis ; Imaging Technique Fluoroscopy
Clinical History
A 40-year old woman who underwent mechanical tubal occlusion 3 months before had a hysterosalpingogram for routine follow-up to confirm occlusion.
Imaging Findings
The antero-posterior radiogram of the pelvis (Fig. 1) demonstrated the presence of linear radiodense coils in the pelvic cavity, with radiodense end-markers. After the instillation of intra-uterine contrast material, the left fallopian tube does not opacify (Fig. 2). The metal density coil is seen within the fallopian tube, with the medial end in the left cornu. The metal markers are aligned and there is neither contrast beyond the coil nor peritoneal contrast extravasation, which indicates the correct position.
On the right, the fallopian tube is filled with contrast that spills into the peritoneum. The coil migrated and extruded into the peritoneal cavity. (Fig. 2)
Discussion
Tubal occlusion devices are an effective, safe and cost-effective mode of contraception. Their use has recently increased. Imaging studies, especially hysterosalphingography 3 months after device insertion, are required to verify function and placement. [1-4]

The Essure system (Conceptus, Mountain View, USA) consists of a coil, which is placed hysteroscopically in the fallopian tubes, causing tubal occlusion due to fibrosis. It has a success rate of 83-94%. [1]

Two grading systems are used to assess contraceptive efficacy according to the hystrosalpingography appearance, one is morphological and the other functional. In the morphological system, adequate positioning corresponds to grade 2: coil placed in the tube with >50% of the lateral end of the coil within the tube and <50% within the uterine cavity, or the medial end of the coil is placed no further than 30 mm from the uterine wall as assessed by contrast filling of the cornu. Grades 1 (>50% of coil within uterine cavity) and 3 (proximal end of the coil >30 mm from the uterine wall) correspond to poor positioning. In the functional system, occlusion at the cornu correlates with grade 1, grade 2 describes tube opacification proximal to the distal end of the device and grade 3 describes opacification beyond the coil regardless of peritoneal spillage. Morphological grade 2 and functional grades 1 or 2 correlate with reliable contraception. [2]

If the device malfunctions or is not well positioned the tube remains patent and follow-up 6 months after placement for confirmation is required. If the findings are confirmed contraception is not assured. Unilateral tubal patency occurs in approximately 3% of cases. [1]

Device migration and expulsion into the endometrial cavity is the most common complication, occurring in 0.6-3% of cases. Device placement too near the uterus increases the expulsion rate. [1]

Uterine and tubal perforation occurs more commonly when the device is placed too peripherally. Rates of perforation are reported at 1-2%. [1] If the pelvic radiograph demonstrates a kink at the peripheral aspect of the coil, tubal perforation should be suspected and assessed. Perforation can lead to extrusion of the coil into the peritoneal and abdominal cavities. Extruded devices should be surgically removed because adhesions and small bowel obstruction can result. [1]

US allows identification of the device. Recent studies demonstrated that adequately positioned coils, as assessed by US, correlate with tubal occlusion. [2]

In summary, after tubal occlusions devices are inserted, imaging is required to assess device placement, function, as well as possible complications.
Differential Diagnosis List
Peritoneal extrusion of tubal occlusion device
Appropriate Essure placement
Essure extrusion
Final Diagnosis
Peritoneal extrusion of tubal occlusion device
Case information
URL: https://eurorad.org/case/12632
DOI: 10.1594/EURORAD/CASE.12632
ISSN: 1563-4086