Sebastiaan Veersema

Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review

To review systematically the medical literature reporting on the prevalence of a niche at the site of a Cesarean section (CS) scar using various diagnostic methods, on potential risk factors for the development of a niche and on niche‐related gynecological symptoms in non‐pregnant women.

Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting

To evaluate the relationship between a niche and abnormal uterine bleeding, and to develop a sonographic classification of niches and evaluate its relationship to abnormal uterine bleeding.

Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization-embryo transfer in patients with a contraindication for laparoscopy

OBJECTIVE To investigate the success rate of proximal tubal occlusion with Essure devices in subfertile women with hydrosalpinges, and to observe the results of subsequent treatment with IVF. DESIGN Prospective, single-arm, clinical study. SETTING University hospital and teaching hospital. PATIENT(S) Ten women with uni- or bilateral hydrosalpinges prior to IVF. In all patients laparoscopy was felt to be contraindicated. INTERVENTION(S) Hysteroscopic placement of Essure devices in an office setting. MAIN OUTCOME MEASURE(S) Placement rate, successful proximal tubal occlusion, and pregnancy rate after IVF. RESULT(S) All patients had successful placement of the Essure devices without any complications. Proximal tubal occlusion was confirmed by hysterosalpingography in 9 out of 10 patients. A 40% ongoing pregnancy rate was achieved with 20% life births after one IVF cycle and/or frozen embryo transfer. CONCLUSION(S) Proximal occlusion of hydrosalpinges with Essure devices before IVF is a successful treatment for patients with a contraindication for salpingectomy.

Long‐term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding

To study the prevalence of niches in the caesarean scar in a random population, and the relationship with postmenstrual spotting and urinary incontinence.

Confirmation of Essure placement using transvaginal ultrasound.

STUDY OBJECTIVE To evaluate the protocol for confirmation of satisfactory Essure placement using transvaginal ultrasound. DESIGN Prospective multicenter cohort study (Canadian Task Force classification II-2). SETTING Outpatient departments of 4 teaching hospitals in the Netherlands. PATIENTS Eleven hundred forty-five women who underwent hysteroscopic sterilization using the Essure device between March 2005 and December 2007. INTERVENTION Transvaginal ultrasound examination 12 weeks after uncomplicated successful bilateral placement or as indicated according to the transvaginal ultrasound protocol after 4 weeks, and hysterosalpingography (HSG) at 12 weeks to confirm correct placement of the device after 3 months. MEASUREMENTS AND MAIN RESULTS The rate of successful placement was 88.4% initially. In 164 women (15%), successful placement was confirmed at HSG according the protocol. In 9 patients (0.84%), incorrect position of the device was observed at HSG. The cumulative pregnancy rate after 18 months was 3.85 per thousand women. CONCLUSION Transvaginal ultrasound should be the first diagnostic test used to confirm the adequacy of hysteroscopic Essure sterilization because it is minimally invasive, averts ionizing radiation, and does not decrease the effectiveness of the Essure procedure.

Tubal perforation by Essure: three different clinical presentations

OBJECTIVE To assess the convenience and safety of Essure sterilization in an outpatient setting and the use of ultrasound as diagnostic tool for verification of proper placement for the 3-month follow-up. DESIGN Prospective cohort study. SETTING Teaching hospital department of obstetrics and gynecology. PATIENT(S) Female patients with a request for permanent tubal sterilization. INTERVENTION(S) Essure sterilization. MAIN OUTCOME MEASURE(S) Bilateral tubal occlusion after Essure sterilization and complication rate. RESULT(S) A total of 149 patients were scheduled for Essure sterilization. Microinsert placement was attempted in 143 patients. Bilateral placement of the device was successful in 95% (95% confidence interval [CI] 92%-99%). Seven attempts were unsuccessful. The complication rate was 2% (n = 3), and all involved a perforation. These three cases are discussed in detail. Vaginal ultrasound was conclusive in 91.7% (95% CI 87%-96%); two perforations were not recognized on the ultrasound. CONCLUSION(S) Essure sterilization is a safe and reliable sterilization method in an outpatient setting. Perforation of the device is the most frequent complication. Vaginal ultrasound is reliable for verification after an uncomplicated procedure. When the procedure is difficult (e.g., higher resistance, more pain then average, more time or more than two devices needed), a hysterosalpingogram should be performed.

Unintended pregnancies after Essure sterilization in the Netherlands

OBJECTIVE To analyze the data of cases of unintended pregnancies after Essure sterilization. DESIGN Retrospective case series analysis. SETTING National multicenter. PATIENT(S) Ten cases of unintended pregnancies after Essure sterilization in the Netherlands were reported from August 2002 through May 2008. INTERVENTION(S) Data on the hysteroscopic Essure sterilization procedures and postprocedure confirmation tests of the reported cases were reviewed and analyzed by two authors. The causes of the unintended pregnancies were determined in agreement with the physicians who performed the sterilizations. MAIN OUTCOME MEASURE(S) Most pregnancies occurred in patients with only one device placement and bilateral occlusion on hysterosalpingography (HSG). Other cases included misinterpretation of HSG, undetected abnormal device position by ultrasound, one undetected preprocedure pregnancy, and two patient failures to follow up with the physician advice. CONCLUSION(S) The risk of pregnancy after hysteroscopic sterilization may be reduced by strictly following the follow-up protocol, performing a urinary pregnancy test on the day of the procedure, and instructing the patient to return for the follow-up visit. A procedure with only a single device placement in a patient without a history of tubectomy of the heterolateral tube should be considered unsuccessful.

Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review

Various therapies are currently used to treat symptoms related to the niche (an anechoic area) in the caesarean scar, in particular to treat abnormal uterine bleeding (AUB).

The international agreement study on the diagnosis of the septate uterus at office hysteroscopy in infertile patients

OBJECTIVE To assess the international agreement on the hysteroscopic diagnosis of septate uterus. DESIGN Interobserver study. SETTING Eight hysteroscopy recordings were put online on the website of the European Society of Gynaecological Endoscopy. PATIENT(S) Asymptomatic, infertile women indicated for a first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment cycle. INTERVENTION(S) Office hysteroscopy. MAIN OUTCOME MEASURE(S) The interobserver agreement on the uterine shape and necessity to correct the abnormality found. RESULT(S) Seventy-eight observers from 24 different countries assessed 8 hysteroscopy recordings. The interobserver agreement on uterine shape variations septate and arcuate was fair (intraclass correlation coefficient = 0.27). Observers from the same country reached a significantly higher level of agreement. The agreement on the necessity of correction was poor (intraclass correlation coefficient = 0.17). The most distinct features for diagnosing a septate uterus judged to be the extent of endocavitary bulging and the angle of the bulging structure from the fundal area. CONCLUSION(S) The agreement among international experts on the hysteroscopic diagnosis of the septate uterus was found to be poor. This may have implications for the accuracy of screening hysteroscopy for diagnosing uterine cavity abnormalities in infertile patients. Development of consented definitions for the hysteroscopic diagnosis of septate and arcuate uterus is recommended.

Observer agreement in the evaluation of the uterine cavity by hysteroscopy prior to in vitro fertilization

BACKGROUND Hysteroscopy is known as the most accurate test for diagnosing intrauterine pathology. To optimize fertility treatment, it is increasingly common to perform hysteroscopy as a routine procedure prior to IVF. However, literature on the reproducibility of screening hysteroscopy is lacking. Therefore, the aim of the study was to assess the intra- and inter-observer agreement in the individual evaluation of the uterine cavity using video recordings of hysteroscopy procedures in asymptomatic patients prior to IVF. METHODS Screening hysteroscopies of 123 unselected, asymptomatic, infertile women with an indication for IVF/ICSI treatment were recorded on DVD. After editing, the hysteroscopy performer and three other experienced gynecologists independently assessed all recordings, focusing on the appearance of predefined intrauterine abnormalities (i.e. endometrial polyps, myomas, adhesions or septa). The intra- and inter-observer agreement was calculated and expressed as perfect agreement and κ coefficient or intraclass correlation coefficient. RESULTS In total, 123 hysteroscopy procedures were recorded. After editing and selection, based on the record quality, 107 remained for assessment and analysis. The intraobserver agreement on the appearance of any of the predefined intrauterine abnormalities was substantial (κ = 0.707), whereas the interobserver agreement was moderate (κ = 0.491). Perfect agreement occurred only in 77.6% of the cases. CONCLUSIONS Interobserver agreement among experienced gynecologists appeared to be rather disappointing. The latter may have implications for the diagnostic accuracy of screening hysteroscopy prior to IVF, as well as for its clinical significance in IVF programs.