The Filshie clip for female sterilization: a review of world experience

Signs and symptoms: Adverse events associated with a sterilization device

Sterilization is now the most common contraceptive method used by women of in the U.S., and sterilization devices have played an important role in its increased popularity. This mixed methods study examines a random sample of 2500 U.S. Food and Drug Administration (FDA) adverse event reports made between 2006 and 2017 about Essure, a sterilization device. Quantitative coding was used to examine patient problems; pain and bleeding were reported most frequently. Qualitative coding analyzed impacts of symptoms on patients' everyday lives and patients' healthcare experiences, including intimate relationships, mothering, and paid employment. Findings suggest that some patients struggled when their reported "subjective" symptoms didn't result in "objective" clinical signs of problems, and when physicians dismissed or deflected their concerns in diagnostic encounters. This paper raises important issues regarding the symptoms patients associated with Essure, the diagnosis of device-driven disease and injury, and the FDA's regulation of medical devices.

Robot-Assisted Tubal Reanastomosis after Sterilization: A Choice for Family Planning

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors related to the choice of the approach. The keywords used for the electronic search in PubMed were family planning, sterilization, Robot-assisted, tubal reanastomosis, depression, and regret. The decision in favor of or against sterilization surgery has been a sensitive issue for several years. Robot-assisted technology is a modern and precise approach. It has contributed to the flexibility of the decision between sterilization and its reversal through tubal reanastomosis, as well as enhanced the success rate of the surgery. Based on our analysis of the published literature, we believe that Robot-assisted tubal anastomosis is the optimum approach. However, to ensure the quality of health care, the surgeon must be well trained, well versed with the anatomy of the fallopian tubes, and thoroughly informed on the psychological impact of family planning.

Long-Term Failure Rates of Interval Filshie Clips As a Method of Permanent Contraception

Background: In 1996, the U.S. Collaborative Review of Sterilization (CREST) reported permanent contraception failure rates by method, but did not include the Filshie clip. Subsequent research provides data for Filshie clip failure rates up to 24 months, but rigorously designed and executed studies examining failure rates beyond 2 years are lacking. Objectives: To describe non-Filshie and Filshie procedures, identify failures, and calculate 10-year pregnancy rates among patients who have undergone interval permanent contraception procedures with Filshie clips. Study Design: We performed chart review for patients who underwent interval permanent contraception procedures between 2000 and 2014 at our institution. We identified births after permanent contraception by utilizing both chart review and the Utah Population Database. We report results from life table analysis, with censoring at failure, 49 years of age, or last observed date of service. Results: In this cohort of 693 patients, surgeons most commonly used Filshie clips for interval permanent contraception (N = 547, 78.8%). We classified pregnancies after Filshie clip procedures as verified (n = 4) or self-reported (n = 3). We obtained 5 years of data for 411 patients (59.3% of all permanent contraception procedures), and more than 10 years of data for 257 patients (37.1%). We calculated a cumulative 5- and 10-year pregnancy rate to be the same, including both verified and self-reported pregnancies, of 9.8 (95% confidence interval [CI] 4.1-23.3)/1000 women using Filshie clips. The 10-year rate of verified pregnancy is 2.8 (95% CI 1.0-15.7)/1000 women. Conclusion: Overall, long-term failure of Filshie clip interval permanent contraception procedures is infrequent, with a 10-year cumulative probability of failure of 4.1-23.3/1000 procedures performed. Filshie clips compare favorably with other methods of permanent contraception included in the CREST study, where the 10-year cumulative probability of failure ranged from 7.5 to 36.5/1000 procedures performed.

Migrated Tubal Ligation (Filshie) Clip as an Uncommon Cause of Chronic Abdominal Pain

Tubal ligation (TL) is an effective and common method of fertility control. In the year 2009, over 24,000 were performed in Canada alone. Migration of Filshie clips used during TL is estimated to occur in 25% of all patients; 0.1-0.6% of these patients subsequently experience symptoms or extrusion of the clip from anatomical sites such as the anus, vagina, urethra, or abdominal wall. Migrated clips may present as chronic groin sinus, perianal sepsis, or chronic abdominal pain. These symptoms can occur as early as 6 weeks or as late as 21 years after application. We present the case of a 49-year-old female with a 3.5-year history of intermittent dull nonradiating left upper quadrant (LUQ) pain lasting on average 2-3 days. There were no other associated symptoms, and the longest pain-free period was 4 days. Her past medical history includes COPD, GERD, IBS, and depression. Current medications are only remarkable for Symbicort. Pertinent past surgical history includes laparoscopic tubal ligation with Filshie clips in 1999, followed by a vaginal hysterectomy in 2013. Migrated tubal ligation clip was noted on an abdominal X-ray. The patient was then referred for surgical management. Subsequent CT scan confirmed a solitary clip present adjacent to the left lobe of the liver. No other abnormalities were reported. Patient underwent laparoscopy for removal of the clip, which was identified to be underneath the left lobe of the liver embedded in the gastrohepatic omentum. Please see the video link provided. Postoperative pathology report confirmed the presence of a Filshie clip. Patient reported complete resolution of her LUQ pain at a 5-week and 3.5-month follow-up. This case shows that although symptomatic clip migration is a rare phenomenon, it should be given special consideration in women with unexplained chronic abdominal pain and a history of TL. Additionally, removal of clip can provide resolution of symptoms.

Falope Rings or Modified Pomeroy's Technique for Concurrent Tubal Sterilization

INTRODUCTION

Sterilization at caesarean section is usually performed by the modified Pomeroy's technique. Application of Falope rings and Filshie clips may also be used for tubal sterilization at caesarean section, and these techniques are also used during laparoscopy or minilaparotomy.

OBJECTIVES

The main objective of the study was to evaluate the failure rates, complications, technical difficulties and reversibility of the Falope ring application for tubal sterilization as compared to the traditional modified Pomeroy's technique used during caesarean sections.

METHODOLOGY

Five hundred multigravid women who underwent caesarean section for various causes and wanted concurrent tubal sterilization were recruited in the study. Two hundred and fifty women underwent tubal sterilization by Falope ring application and the other 250 by modified Pomeroy's technique. Follow-up period ranged from 3 to 42 months. These patients' names were checked against the antenatal booking register, the operating theatre register in case of ectopic pregnancies and a termination of pregnancy register to recognize failed sterilization.

RESULTS

Among the 250 women who underwent Falope ring application, no major complications were noted. In the other group, women who underwent tubal sterilization by modified Pomeroy's technique, there was one woman with serious complication, ectopic pregnancy. Falope ring application was an easy procedure to perform and also less time-consuming than modified Pomeroy's technique.

CONCLUSION

Falope ring sterilization is simple, effective and safe, and the rate of subsequent pregnancy is lower than with conventional modified Pomeroy's technique.

Filshie clip migration with multiple groin hernias: a case report

Introduction

Tubal occlusion is a common form of contraception. Filshie clips have been widely used for tubal occlusion since their introduction. Reports of Filshie clip migration are rare. We describe what we believe to be the first reported case of a patient with multiple groin hernias associated with migration of a Filshie clip.

Case presentation

We report the case of 56-year-old Caucasian woman who presented with a tender right groin lump. She had undergone a right-sided inguinal hernia repair 3 years earlier. Tubal occlusion had been performed using Filshie clips 21 years prior. Computed tomography revealed a tubal clip within her right inguinal region, and had also been identified on imaging prior to a previous hernia repair. Our patient underwent repair of a right femoral hernia, with the tubal clip identified in the sac and removed. She has since had no recurrences.

Conclusion

Filshie clip migration is a rare event, with occasional complications occurring. This case highlights the importance of identification and removal of such foreign bodies, potentially reducing the risk of hernia recurrence or further complications.

Currently available devices for female sterilization

Sterilization is now the method of family planning most commonly used in the world. Over the last 150 years, research has evolved in the search for the ideal method of female sterilization. The procedure should ideally have high efficacy, be readily accessible and be personally and culturally acceptable. The method should be simple, quick, easily learned and be able to be performed in an outpatient setting without general anesthesia. The most common and effective method for sterilization has, thus far, been via the laparoscopic route. Hysteroscopic sterilization, however, potentially fulfills many of these ideal criteria, but until recently has remained more of a concept than a reality.

Long-term risk of ectopic pregnancy varies by method of tubal sterilization: a whole-population study

OBJECTIVE

To evaluate the risk of ectopic pregnancy (EP) associated with different methods of tubal sterilization.

DESIGN

Population-based retrospective cohort study.

SETTING

Hospitals in Western Australia.

PATIENT(S)

All women aged 18-44 years undergoing tubal sterilization between 1990 and 2010 at Western Australian hospitals (n = 44,829).

INTERVENTION(S)

Data on tubal sterilization were extracted from hospital records.

MAIN OUTCOME MEASURE(S)

Long-term risk of EP.

RESULT(S)

There were 89 EPs recorded during the observation period in women previously sterilized. The 10-year and 15-year cumulative probability of EP for all methods of tubal sterilization were 2.4/1,000 and 2.9/1,000 procedures, respectively. The 10-year cumulative probability of EP was 3.5 times higher in women sterilized before the age of 28 years than in those sterilized after the age of 33 years. An increased risk of EP existed in women who received laparoscopic partial salpingectomy (adjusted hazard ratio = 14.57, 95% confidence interval 3.50-60.60) and electrodestruction (adjusted hazard ratio = 5.65, 95% confidence interval 2.38-13.40), compared with those who had laparoscopic unspecified destruction of fallopian tubes.

CONCLUSION(S)

Women undergoing tubal sterilization at a young age are at particular risk for subsequent EP. The risk among younger women doubled between 5 and 15 years after sterilization. Laparoscopic electrodestruction and partial salpingectomy carried the highest risk of EP.

A comparison of the modified Pomeroy tubal ligation and Filshie clips for immediate postpartum sterilisation: a systematic review

OBJECTIVES

The modified Pomeroy procedure is currently the most widely used method for postpartum sterilisation. Alternative options are Filshie clips, Hulka-Clemens clips and Falope rings. In this systematic review we pooled the available evidence in order to compare the failure rates, complications, technical difficulties, and reversibility of the Pomeroy method and Filshie clips when resorted to for postpartum sterilisation.

METHODS

We gathered data from MEDLINE, EMBASE (1970-2010), the Cochrane database, and reference lists of randomised controlled trials (RCTs) and observational studies. We extracted information on study design, sample characteristics, interventions, and outcomes.

RESULTS

Our search yielded 294 citations of which 43 were retrieved for detailed evaluation. Fourteen studies were included in the systematic review. One RCT and three observational studies compared failure rates of the Pomeroy method vs. Filshie clips. A random-effects analysis of the pooled studies showed no difference in the failures rates between these two methods (odds ratio 0.76 [95% confidence interval 0.30-1.95]). Complication rates were similar although the Filshie clip technique was reported to be easier.

CONCLUSIONS

Filshie clip application is easier to perform. The failure and complication rates are comparable to those of the modified Pomeroy method, when performed in the postpartum period.

Laparoscopic laser sterilisation: An alternative option

The aim of this prospective study was to evaluate the safety and efficacy of female laparoscopic laser tubal sterilisation. A total of 265 women underwent laparoscopic laser sterilisation as a day-case procedure at Princess Royal University Hospital in Kent between 1996 and 2001. The fallopian tube was divided at the isthmic portion using a neodymium-yttrium aluminium garnet (Nd:YAG) laser probe. All procedures were completed laparoscopically and patients were discharged within 6 h of surgery. No perioperative complications were encountered. The mean follow-up duration was 36 months (range 2 - 7 years) and no intra- or extrauterine pregnancies were reported throughout the entire follow-up period. We conclude that laparoscopic Nd:YAG laser sterilisation appears to be a safe and effective day-case method of female sterilisation. Larger studies with longer follow-up are needed to further define its role as a reliable long-term contraceptive method.

Filshie clip closure: determination of closure through the analysis of X-rays

The Filshie method is a tubal occlusion method commonly used to prevent pregnancy. In medical negligence cases where it is suspected that closure of a Filshie clip may be faulty, lawyers may call on expert surgeons to assess whether or not a clip is closed on the basis of visual examination of the X-rays. However, it is not uncommon for experts to disagree. The aim of this work was to reduce the uncertainty in determining whether or not Filshie clips had been correctly closed. An estimate of the error in the estimate of the clip height was made by propagating measurement errors through a mathematical model. The effects of angle of presentation of the clip, digitisation of the image and resolution of the measurements were studied and the method was applied to two cases. The analysis indicated that measurement errors were least when the digitisation of the image was at 600dpi, angle of presentation of the clip was less than 40 degrees and the measurements could be made to an accuracy of +/-1pixel. Under these conditions it was possible to determine clip closure height with an error of less than +/-0.2mm.

Management of chronic pelvic pain additional to tubal sterilization

OBJECTIVE

A case series is presented to illustrate the dilemma in management of women with Chronic Pelvic Pain (CPP) additional to a tubal sterilization.

METHODS

Between January 1999 and June 2007, five women consulted the Department of Gynecology for CPP additional to tubal sterilization with Filshie Clips (FCs). A biopsychosocial approach of the complaint was offered and laparoscopic removal of the clips was performed in all cases. The effectiveness of this management was assessed by a personal interview and a retrospective chart review.

RESULTS

Two of the five patients refused an exploration of psychosocial factors possibly contributing to or maintaining the pain. During laparoscopic removal of the Filshie Clips no additional pathology was noted. At follow-up four women declared to have benefited from the removal procedure.

CONCLUSION

If women present with CPP additional to sterilization with FCs in the absence of obvious pathology, gynecologists have to pay attention to the possibility of underlying psychosocial factors to this complaint. However, this attention can be in conflict with the woman's conviction that only removal of the clips will alleviate her pain. In that case, laparoscopic removal might be a component of the management.

Failure of sterilization after clip placement

BACKGROUND

Tubal sterilization is a common method of contraception used worldwide. The Filshie clip is a device designed to occlude the fallopian tubes. It is common practice to apply the clips across the isthmus using laparoscopy. It is often suggested that failures occur due to problems with the technique used to occlude the fallopian tubes.

CASE

After insertion of an intrauterine device, a patient experienced an unplanned pregnancy and subsequent abortion. The intrauterine device was removed, and bilateral Filshie clips were applied by an experienced surgeon. After this procedure, the patient experienced a second unplanned pregnancy and subsequent abortion. A partial salpingectomy was performed after the fallopian tubes were examined, and it was confirmed that the Filshie clips were applied appropriately.

CONCLUSION

It is important to understand why sterilization clips lead to contraceptive failure and to inform patients of this risk. Contraceptive failure after female sterilization remains a medical issue.

Surgical clips: a nidus for foreign body reaction after hepatic resection

This case report describes a patient who underwent segment IV hepatic resection and 7 months later developed an abdominal wall abscess. This was a foreign body reaction to the surgical clips. The patient required an exploratory laparotomy with debridement and excision of the inflammatory mass in the anterior abdominal wall. Although occurrence is rare, foreign body reactions to surgical clips have been reported, especially as a complication of laparoscopic surgery.

Effect of topical bupivacaine on postoperative pain after laparoscopic tubal sterilization with Filshie clips

OBJECTIVE

The purpose of this study was to evaluate postoperative pain after the administration of topical bupivacaine during laparoscopic sterilization with Filshie clips.

STUDY DESIGN

Sixty-three women who underwent laparoscopic tubal sterilization with Filshie clips were assigned randomly to receive topical bupivacaine or placebo. Presence of pain, pain intensity, nausea, vomiting, timing of request for pain medication, and pain medication requirements were assessed postoperatively.

RESULTS

Patient demographics were similar between the 2 groups. Topical bupivacaine decreased the incidence (P=.005) and intensity (P=.028) of postoperative pain at 30 minutes. No differences in incidence or severity of pain were seen at hospital discharge or on postoperative day 1.

CONCLUSION

Topical bupivacaine that is applied to the fallopian tubes at the time of laparoscopic tubal sterilization with the Filshie clip decreases immediate postoperative pain.

Prospective randomized, controlled study of postoperative pain after titanium silicone rubber clip or Silastic ring tubal occlusion

OBJECTIVE

To determine if laparoscopic sterilization using the Filshie clip causes less postoperative pain as compared to the Falope ring during the first 24 h after surgery.

STUDY DESIGN

Forty subjects were enrolled. Five milliliters of 0.5% bupivicaine was injected at each of the two incision sites and 5 mL was dripped onto each fallopian tube. Subjects then received one Filshie clip and Falope ring on opposite fallopian tubes; the side of occlusion was randomized. Subjects were questioned about pain prior to the first administration of analgesics postoperatively, 1 and 2 h after surgery, at discharge, and 24 h after surgery.

RESULTS

Forty subjects completed the study; 32 without major deviations from protocol. There was no significant difference in pain between sides with the Filshie clip or Falope ring at any times evaluated.

CONCLUSION

There was no significant reduction in the postoperative pain associated with the Filshie clip as compared to the Falope ring within 24 h after surgery.

Female sterilization: an update

Female sterilization is the most popular form of birth control in the world. It is performed laparoscopically or through a minilap, depending on the timing (postpartum) and where the patient lives. It is a safe and efficacious procedure with few complications that can be performed under local or general anaesthesia. The techniques presently in use are all adequate and the choice should evolve from a discussion between the doctor and the patient.

Spontaneous opening of the Filshie clip as a cause of sterilisation failure

An open Filshie clip is sometimes detected during the evaluation of a case of sterilisation failure. This spontaneous opening of the clip does not need to have been caused by material failure, but may be produced by jamming of the clip what can occur by incorrect squeezing during closure. On superficial observation, the clip will appear to be closed, but it may easily open itself by its spring mechanism when the clip is moved or merely touched. Especially in the teaching situation one should be careful for this lapse.