Problems Reported with Essure

The FDA relies on adverse event and product problem reports, FDA-mandated postmarket studies, and published literature to monitor the safety and effectiveness of medical devices. The FDA reviews the available information about Essure and the experiences of patients who have or had Essure implants. This includes experiences of patients who had positive outcomes with Essure as well as those who experienced problems.

As of December 31, 2019, all unused Essure units should have been returned to Bayer and are no longer available for implantation. Even though Essure is no longer sold or distributed in the United States, the FDA will continue to evaluate medical device reports related to Essure and will keep the public informed if new information becomes available.

Adverse event and product problem reports submitted to the FDA are one source the FDA uses to monitor the safety profile of medical devices. These reports may contribute to the detection of potential device-related safety issues as well as to the benefit-risk assessments of these devices. While such reports are a valuable source of information, this type of reporting system has notable limitations, including the potential submission of incomplete, inaccurate, untimely, unverified, or biased data. This can make it difficult for the FDA to confirm whether a device caused a specific event based only on the information provided in a medical device report. Complaints or adverse event reports do not necessarily directly indicate a faulty or defective medical device, and adverse event reports alone cannot be used to establish or compare rates of event occurrence. Additionally, the FDA may receive multiple reports related to the same event, making it difficult to determine actual numbers of events.

Medical Device Reports Received by the FDA Related to Essure (2002-2023)

The FDA conducted a search of the Manufacturer and User Facility Device Experience (MAUDE) database on February 12, 2024. From November 4, 2002, Essure's approval date, through December 31, 2023, the FDA received 72,875 medical device reports related to Essure. Most reports received between 2013 and 2015 were voluntary reports submitted from women who received Essure implants. Beginning in 2016, Bayer (the company that manufactured Essure) submitted most of the reports received by the FDA. In 2023, Bayer submitted 99% of the reports received by the FDA.

The total number of medical device reports received related to Essure in 2023 is 3,626. In 2022, the FDA received 1,606 medical device reports related to Essure, with 3,701 reports received in 2021, 16,086 reports received in 2020, 15,083 reports received in 2019, 6,000 reports received in 2018, and 11,854 reports received in 2017. The nature and severity of the reports in 2023 remain consistent with prior years. In 2023, 76% of all submitted reports cited litigation. In 2022, 44% of reports cited litigation, with 63% in 2021, 91% in 2020, 95% in 2019, and 73% in 2018 and 2017. Litigation reports may reference information previously submitted to the FDA.

In 2017, 2018, 2019, 2020, 2021, and 2022, 92.7%, 87.5%, 91%, 93.5%, 85.7%, and 86.9% respectively, of all reports received used terms related to device removal. In 2023, 93.9% of reports received used terms related to device removal. Some of these reports may not indicate that the device was removed or the date of removal. The FDA continues to evaluate other sources of postmarket data, including results from mandated postmarket studies, in addition to medical device reports to gather more information about device removals.

From 2002 through 2023, the most reported patient problem codes were pain/abdominal pain (40,490), heavier menses/hemorrhage/menstrual irregularities (17,732), foreign body/device fragment in patient (10,446), perforation (9,682), headache (8,743), fatigue (7,234), weight fluctuations (6,099), depression/anxiety (5,762), hypersensitivity/rash (5,429), and hair loss (5,114). Most of the reports received listed multiple patient problem codes in each report. The most frequent device problem codes reported were patient-device incompatibility/biocompatibility (for example, possible nickel allergy or patient's anatomy related to failure) (8,862), migration of the device or device component (5,949), device breakage/material fragmentation/fracture (3,142), dislodged or dislocated device (3,027), device operating differently than expected, for example, implant failure or pregnancy (1,137), malposition of the device (416), device difficult to remove (355), and device difficult to insert (344). Multiple device problem codes can also be listed in each report.

Through December 31, 2023, there have been 100 reports coded by the submitter as death. Eight of these were incorrectly coded, as there was no indication of death in the report. Of the remaining 92, 29 reports relate to 27 adult deaths; 25 reports relate to 22 incidences of pregnancy loss; five reports relate to five incidents of a death of an infant after live birth; two reports relate to two incidences of ectopic pregnancies (a complication of pregnancy in which the fertilized egg attaches outside the uterus); one report specifies a death but does not indicate whether the death occurred before or after birth; and 30 reports reference information on deaths posted in social media or other media outlets. It is difficult for the FDA to determine whether the device caused the death with only the information provided in the report.

The FDA has received a total of 4,618 reports of pregnancies in patients with Essure from 2002 through 2023. Some reports contained information on multiple pregnancies or more than one pregnancy loss. Of the total reports: 1,077 live births were reported; 1,701 did not indicate whether the pregnancy resulted in a live birth or pregnancy loss; and 2,339 pregnancy losses were reported.

Among the 2,339 pregnancy losses reported: 596 were reported as ectopic pregnancies; 281 were reported as elective terminations of pregnancies, and 1,195 were reported as other pregnancy losses. Some reports did not indicate the context of the pregnancy loss. Due to the limited information provided in the reports, the FDA cannot determine whether pregnancy loss is due to the device.

Variance Adverse Event Reports (June 2020-March 2021)

As outlined in its April 24, 2020 letter to Bayer, the FDA granted Bayer's request for a variance from Medical Device Reporting (MDR) requirements for adverse event information about Essure in social media. Bayer had received adverse event information between November 2016 through November 2020 as part of litigation. The FDA required Bayer to process all reportable adverse events contained in this information within one year. Bayer completed its reporting of this information and met the requirements of the variance.

Bayer submitted the adverse event information under the variance in ten reporting spreadsheets, during the reporting period of June 2020 through March 2021. The reports do not necessarily represent unique cases, but rather events identified in comment threads from social media posts received as part of litigation. The ten spreadsheets of reportable adverse events are publicly available, see Essure Variance Reports. Summary information about the events in each spreadsheet is also accessible in the FDA's MAUDE database. On September 29, 2021, Bayer posted a final analysis report of the adverse event information submitted under the variance.

In total, there were 57,802 reportable events submitted under the variance with the following report types: 57,099 serious injury reports, 588 malfunction reports, and 115 death reports. Most of the reports were related to potential device removal (91%) which is consistent with the MDRs for Essure from 2017 to 2021. The most common patient problems reported were pain, perforation, foreign body/device fragments in patient, pregnancy, heavier periods (menses/hemorrhage), and hypersensitivity. The most common device problem reported was breakage. The social media posting dates for reported events (when provided) were mostly between the years of 2014 to 2016. The dates of reported events (when provided) were mostly during or before 2016.

For the 115 death reports, the social media posting dates (when provided) were mostly between the years of 2013 to 2016. Three of the death reports provided a date of the death: one in 2012 for a reported death of an infant after birth, and two in 2013, both for reported adult deaths.

As this adverse event information was based on social media posts received as part of litigation, the reports submitted under the variance may reference information previously reported to the FDA and do not necessarily represent new adverse events. Based on the limited information in the event descriptions for the reports, it is difficult to identify duplicate reports for events within the variance as well. The limited information and the nature of the information limits the ability to draw conclusions as to whether the device, or its removal, caused or contributed to any of the reported deaths or other events in the reports.

Device Removal Medical Device Reports (2017-2018)

Prior to interim results being available from the Essure postmarket surveillance ("522") study, the FDA completed an extensive evaluation of medical device reports submitted in 2017 and 2018 that mentioned issues involving potential device removal to learn more about why women were choosing to have the device removed, which usually requires a surgical procedure. This involved evaluating more than 17,000 medical device reports submitted to the FDA in 2017 and 2018 on the Essure device. Most of these reports referenced an instance in which the device was removed from a patient, and most came from cases that were made available by plaintiff attorneys as part of litigation against the manufacturer Bayer.

From January 2017 through December 2018, there were 11,854 medical device reports related to Essure in 2017 and 6,000 reports in 2018. Of those reports, 85% referenced an instance in which the device was removed from a patient (referred to as "device removal reports" from here after).

80% of the device removal reports cite litigation.
The top six reported reasons in the device removal reports were:
- Pain: 60%,
- Genital hemorrhage: 14%,
- Device dislocation/migration/expulsion: 12%,
- Perforation: 11%,
- Suspected allergy to metals: 4%, and
- Device breakage: 3%.

Most individual reports included more than one reason for device removal.

66% of the device removal reports did not provide information regarding patients' outcomes after device removal (or the outcome was unknown).
Of the 34% device removal reports that did provide information about patients' outcomes:
- 43% stated patient symptoms resolved after device removal;
- 45% stated patient symptoms partially resolved (meaning only some of the symptoms resolved or symptoms were in the process of resolving); and
- 12% stated patient symptoms were not resolved or improved.
10% of the device removal reports suggest complications directly related to device removal. The most reported complications related to Essure device removal were:
- Device breakage,
- Coil migration,
- Device fragments remaining in the patient,
- Procedural or post-procedural hemorrhage, and
- Uterine or fallopian tube perforation.
60% of the device removal reports specified a date in which the device was removed. Device removal reports included explant dates ranging from the year 2003 to 2018.
50% of the device removal reports provided both an implant and an explant date. In these reports, the mean and median time from implant to explant were both approximately 4.5 years.

The FDA continues to evaluate other sources of postmarket data, including results from mandated postmarket studies, in addition to medical device reports to gather more information about device removals.