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Obstetric sterilization following vaginal or cesarean delivery: A technical update

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References

Making the short applicator available

DR HARKINS: During my residency in 1996, the Filshie clip became popular as a laparoscopic technique. It was at the forefront of my training, although we did learn how to use the Falope ring, etc. I had seen the Filshie clip—with the short applicator—used in obstetric postpartum procedures. But we primarily used the Pomeroy method in that setting.

In 2000, when I was at Fort Hood, Texas, the Filshie clip, with its short applicator, was available in the labor and delivery OR. I believe that its availability in this setting is what encouraged me to use it. During their training, most ob/gyns see the Parkland or Pomeroy methods used for postpartum tubals. It doesn’t occur to them to use the Filshie clip in obstetric cases until they see the short-handle applicator, which is specifically made for obstetric use.

History of tubal sterilization in the United States

1880
First reported tubal sterilization at time of C-section performed by Samuel Smith Lungren of Toledo, Ohio

1896
Debate on whether a woman had the right to choose to undergo sterilization, held at the 21st annual meeting of the American Gynecological Society

1970
Number of tubal sterilizations performed in the United States: 201,000

1972
Federal courts strike down legal restrictions to tubal sterilization for nonmedical reasons

1977
Number of tubal sterilization procedures performed in the United States: 702,000

Reversing sterilization

DR SANFILIPPO: It’s important for the device to be readily accessible. For me, the question is “How do we get the short applicator into more surgeons’ hands and get them to think more about performing obstetric-related sterilization with this device?” I’ve always been a fan of the Filshie clip because it’s quick and effective.

As important, it’s a joy to reverse a sterilization that has been performed with this technique. We need to keep in mind that we can’t be certain that the patient—particularly a younger woman—will be happy in the long term with her decision to undergo sterilization. It’s comforting to know that with the Filshie clip, reversal of the sterilization procedure is generally easy to perform and carries a higher success rate compared with procedures that result in greater tubal destruction.

Choosing Filshie vs sutures

DR HARKINS: At our institution, the decision of which technique to use is based on the individual physician’s preference. I estimate that 1 in 4 sterilization procedures are done with the Filshie clip. Often, the staff base their decision on the tubal anatomy they find when performing a C-section.

DR KAUNITZ: Since both the Pomeroy method and the Filshie clip are used in your C-section rooms, what has been your experience with the speed or convenience of the Filshie clip compared with the Pomeroy method?

DR HARKINS: I find the outcomes identical to those that you reported in your article in Contraception (TABLE 2).3

The procedure is performed more quickly with the Filshie clip, and this device is easier to use. At our institution, the scrub technicians are the ones who often ask us to use the Filshie clip because they see that it’s fast and efficient.

DR SANFILIPPO: I’ve had the same experience, but I want to add that the Filshie clip features the least tubal damage—an important point in performing reconstructive surgery. Only 4 mm of tube is affected by clip application.4

Reducing risk of bleeding

DR KAUNITZ: We are all familiar with the risk of mesosalpingeal bleeding associated with the Pomeroy method, whether used postpartum via minilaparotomy or at the time of cesarean delivery. The knots or sutures may slip off the cut ends of the tube; this results in persistent postoperative bleeding, perhaps with hemoperitoneum, low hemoglobin, or hypovolemia, which requires relaparotomy.

DR HARKINS: That’s very important—we’ve all had a patient or know a colleague whose patient had to return to the OR because of a hemorrhage in the broad ligament vessel. Obviously, you remember those cases and want to avoid such occurrences. Certainly, using the Filshie clip is a way of eliminating the worry about this complication.

DR KAUNITZ: Although we have no clinical trial data to prove that the Filshie clip results in fewer complications, I feel it is prudent to use a method, such as the Filshie clip, in that it is as effective as others that are available but that it also enables us to minimize unusual negative occurrences.

Review of postpartum procedures and devices

Pomeroy method

Developed in 1930, the Pomeroy method is highly effective and relatively inexpensive, although additional costs are incurred for pathology. This technique is associated with a small risk of postoperative mesosalpingeal bleeding, which often requires reoperation.

In this procedure, the tubes are grasped with a clamp and formed into a loop. A suture is tied around the loop, and the portion of the tube within the loop is cut.1

Filshie clip

The Filshie clip consists of a titanium (nonferrous) clip, 14 mm long, 4 mm wide, and 0.36 g in weight. It is lined with a silicone cushion, which facilitates occlusion of swollen and fragile fallopian tubes characteristic of the immediate postpartum period. The clip construction creates minimal damage to the surrounding structures.2,3 Only 4 mm of tube is destroyed, thus facilitating reanastomosis.4,5 There is no risk from the magnetic effects of future MRI investigations.

The soft silicone lining is associated with substantial clip capacity and may reduce transection and fistula formation in the tubal stump. When applied over the tube, the clip immediately compresses and occludes the tube. As necrosis occurs, the lining expands and maintains blockage. Eventually, the tube divides and the closed stump heals.3 The large tubal capacity allows the procedure to be performed in women with thick fallopian tubes or whose tubes may be edematous, as may occur postpartum.

The procedure is associated with a low failure rate of approximately 2.7 per 1000 patients. It obviates the potential risk of bowel burn and does not require the use of instrumentation that may lacerate blood vessels.

Filshie clip application steps

The Filshie clip is applied across the entire diameter of the isthmic portion of the fallopian tube with the hooked end of the lower jaw visible through the mesosalpinx. Before closure, the applicator manipulates the structures to properly identify the tube(s) and confirm correct clip placement. The applicator is squeezed to compress and flatten the upper jaw, locking it under the hooked end of the lower jaw. The applicator is removed, leaving the locked Filshie clip compressing the entire diameter of the tube within its jaw. One Filshie clip per fallopian tube is required; clips are permanently implanted.

Hulka clip system

This device features a Lexan plastic jaw, attached with goldplated stainless steel spring “teeth” and a plastic tip. The length of the clip makes complete occlusion of some tubes challenging.

Hulka clip system steps

The clip is attached to the fallopian tube at the isthmus, with the tube placed on stretch. The clip must be applied exactly perpendicular to the long axis of the tube to fully enclose the tube, with the hinge jaw of the open clip adjacent to the tube and the clip jaws extending onto the mesosalpinx. After correct placement, the jaws of the clip are closed.6

As part of the procedure, 1 cm of tissue is destroyed. Sterilization can be reversed. The failure rate is substantially higher than other laparoscopic techniques.

Parkland method

In this procedure, the tube is identified and elevated. The proximal and distal portions of the tube (2 cm) are ligated and the remaining tube is excised to reduce the risk of natural reattachment.

The procedure is associated with low failure rates (7.5/1000). It is inexpensive (if no pathology is required). Although rare, complications include the risk of ectopic pregnancy, infection, and bleeding. The procedure requires more time to perform than do currently used methods.1

Irving technique

The results of sterilization with this method were published in 1924. It has been used with cesarean delivery. The procedure is moderately difficult to perform. Both the Pomeroy and Parkland methods are quicker and easier to perform. The reported failure rate of the Irving technique is 2.3 per 1000 patients.7

Uchida procedure

Introduced by Hajime Uchida in the 1940s, this procedure can be performed immediately postpartum. The procedure is moderately difficult to perform. The Pomeroy and Parkland methods are quicker to perform. Uchida personally performed more than 20,000 cases without a failure.8

References

1. Peterson HB. Sterilization. Obstet Gynecol. 2008;111:189-203.

2. Kohaut BA, Musselman BL, Sanchez-Ramos L, et al. Randomized trial to compare perioperative outcomes of Filshie clip vs Pomeroy technique for postpartum and intraoperative cesarean tubal sterilization: a pilot study. Contraception. 2004;69:267-270.

3. Yan J-S, Hsu J, Yin CS. Comparative study of Filshie clip and Pomeroy method for postpartum sterilization. Int J Gynecol Obstet. 1990;33:263-267.

4. Filshie clip [package insert]. Trumbull, CT: Cooper Surgical, Inc. 2005.

5. Penfield AJ. The Filshie clip for female sterilization: A review of world experience. Am J Obstet Gynecol. 2000;182:485-489.

6. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from one US Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174:1161-1168.

7. Lopez-Zeno JA, Muallem NS, Anderson JB. The Irving sterilization technique: a report of a failure. Int J Fertil. 1990;35:23-25.

8. Sklar AJ. Tubal Sterilization. eMedicine. Nov 15, 2002. http://www.emedicine.com/med/topic3313.htm. Accessed Feb 7, 2008.

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