Figure 9.

A 44-year-old female who underwent tubal sterilization with Essure implants. The procedure was noted as difficult because of poor visibility and a right-sided tubal spasm. (a) Scout image showing asymmetrical inserts. (b) Hysterosalpingogram showing bilateral tubal occlusion despite a misplaced right implant. Peritoneal extrusion was suspected because the insert wasn’t projected inside the uterine cavity (arrow). (c) Delayed HSG image. The patient experienced shortly afterward, a vaginal expulsion of the right insert. This was due to a proximal migration of the insert that positioned itself in the vaginal fornix (arrow), which is consistent with the imaging findings of the image (c). In this case, differentiating between a localization in the recto-uterine pouch and the vaginal fornix cannot be done on radiographic or HSG images. Peritoneal extrusion was suspected because the implant was lodged in the pelvic area for 3 months after the procedure and should have been extruded vaginally earlier in the follow-up period. An approach with a CT scan would have been better suited to localize the implant with more precision. HSG, hysterosalpingography.