Two randomized controlled trials comparing the tubal ring and filshie clip for tubal sterilization

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.

Biomaterials and Contraception: Promises and Pitfalls

The present state of reproductive and sexual health around the world reveals disparities in contraceptive use and effectiveness. Unintended pregnancy and sexually transmitted infection transmission rates remain high even with current prevention methods. The 20th century saw a contraceptive revolution with biomedical innovation driving the success of new contraceptive technologies with central design concepts and materials. Current modalities can be broadly categorized according to their mode of function: reversible methods such as physical/chemical barriers or hormonal delivery devices via systemic (transdermal and subcutaneous) or localized (intrauterine and intravaginal) administration, and nonreversible sterilization procedures such as tubal ligation and vasectomy. Contraceptive biomaterials are at present dominated by well-characterized elastomers such as polydimethylsiloxane and ethylene vinyl acetate due to their favorable material properties and versatility. Contraceptives alter the normal function of cellular components in the reproductive systems to impair fertility. The purpose of this review is to highlight the bioengineering design of existing methods, explore novel adaptations, and address notable shortcomings in current contraceptive technologies.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3627 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures appear to be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3827 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was statistically significantly higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures may be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

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.

Female sterilization and refertilization

OBJECTIVE

To analyze data on sterilization and refertilization procedures that took place at Orbis Medical Center in Sittard, a hospital in the south of the Netherlands.

STUDY DESIGN

Retrospective cohort study of surgical tubal sterilizations performed on 966 patients for contraception between 2002 and 2011, and of 19 patients who underwent refertilization between 2002 and 2012. The main outcome measures were complications and failure rates of sterilization, motives for refertilization and pregnancy rates after refertilization. The t test and nonparametric tests were used to determine differences between groups and proportions.

RESULTS

Between 2002 and 2011, the number of sterilizations declined. Almost all the patients (99.8%) underwent laparoscopic sterilization. The most common method of sterilization used Filshie clips, and was used in 99.7% of the women. The median age at the time of sterilization was 37 years. The failure rate was 0.3%. All procedures were uneventful. The number of refertilizations during this time period also declined. The median time between sterilization and refertilization was 65 months. Patients who underwent refertilization were significantly younger at time of sterilization than patients who did not (p<0.001). After refertilization, 12 patients (63.2%) became pregnant.

CONCLUSIONS

The complication and failure rates of laparoscopic sterilization are low. The number of laparoscopic sterilizations and the number of refertilizations are both declining. Still, refertilization is a safe procedure and gives a significant chance of becoming pregnant.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

Female sterilisation is the most popular contraceptive method worldwide. Several techniques are described in the literature, however only few of them are commonly used and properly evaluated.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' views.

SEARCH STRATEGY

Originally MEDLINE and The Cochrane Controlled Trials Register were searched. For the 2010 update, searches of Popline, Lilacs, Pubmed and The Cochrane Controlled Trials Register were performed. Reference lists of identified trials were searched.

SELECTION CRITERIA

All randomised controlled trials comparing different techniques for tubal sterilisation, regardless of the route of Fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Nine relevant studies were included and the results were stratified in five groups: tubal ring versus clip, modified Pomeroy versus electrocoagulation, tubal ring versus electrocoagulation, modified Pomeroy versus Filshie clip and Hulka versus Filshie clip. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

Tubal ring versus clip: Minor morbidity was higher in the ring group (Peto OR 2.15; 95% CI 1.22, 3.78). Technical difficulties were found less frequent in the clip group ( Peto OR 3.87; 95% CI 1.90, 7.89). There was no difference in failure rates between the two groups (Peto OR 0.70; 95% CI 0.28, 1.76). Pomeroy versus electrocoagulation: Women undergoing modified Pomeroy technique had higher major morbidity than those with the electrocoagulation technique (Peto OR 2.87; 95% CI 1.13, 7.25). Postoperative pain was more frequent in the Pomeroy group (Peto OR 3.85; 95% CI 2.91, 5.10). Tubal ring versus electrocoagulation: Post operative pain was more frequently reported in the tubal ring group. No pregnancies were reported. Pomeroy versus Filshie clip: In the only trial comparing the two interventions only one pregnancy was reported in the Pomeroy group after follow-up for 24 months. No differences were found when comparing Hulka versus Filshie clip in the only study that compared these two devices.

AUTHORS' CONCLUSIONS

Electrocoagulation was associated with less morbidity including post-operative pain when compared with the modified Pomeroy and tubal ring methods, despite the risk of burns to the small bowel. The small sample size and the relative short period of follow-up in these studies limited the power to show clinical or statistical differences for rare outcomes such as failure rates. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.

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.

Spontaneous expulsion of tubal ligation clips: a case report

BACKGROUND

A rare complication of tubal ligation, expulsion of tubal clips has been sporadically reported in the literature.

CASE

An otherwise well multiparous woman who had undergone two operative deliveries and a tubal ligation presented with menstrual discharge from her laparotomy incision. Following two surgical procedures to excise fistulous tracts, the patient spontaneously expelled three Hulka tubal ligation clips from the vagina.

CONCLUSION

Migration of tubal ligation clips and extrusion with associated tuboperitoneal fistula is a rare outcome of tubal ligation. Individual patient reactions to the presence of supposedly inert objects in the peritoneal cavity are unpredictable.

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.

Pregnancy after hydrothermal endometrial ablation and laparoscopic sterilisation

Hydrothermal ablation (HTA) is a newly introduced technique of endometrial ablation. This report describes the first case of pregnancy and miscarriage following successful HTA performed 4 years after laparoscopic tubal sterilisation. The diagnosis of such pregnancies can be difficult and the risk of pregnancy complications is potentially increased.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

Female sterilization is the most popular contraceptive method worldwide. Several techniques are described in the literature, however only few of them are commonly used and properly evaluated.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties and women's and surgeons' views.

SEARCH STRATEGY

The Cochrane Controlled Trials Register has been searched. A search of the reference lists of identified trials was performed. An additional MEDLINE search was done using an Internet search service Pub Med.

SELECTION CRITERIA

All randomized controlled trials comparing different techniques for tubal sterilization, regardless of the way of entry in the abdominal cavity or the method of anesthesia.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Nine relevant studies were included and the results were stratified in five groups: tubal ring versus clip, modified Pomeroy versus electrocoagulation, tubal ring versus electrocoagulation, modified Pomeroy versus Filshie clip and Hulka versus Filshie clip. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

Tubal ring versus clip: Minor morbidity was higher in the ring group (Peto OR 2.15; 95% CI 1.22, 3.78). Technical difficulties were found less frequent in the clip group ( Peto OR 3.87; 95% CI 1.90, 7.89). There was no difference in failure rates between the two groups (Peto OR 0.70; 95% CI 0.28, 1.76). Pomeroy versus electrocoagulation: Women undergoing modified Pomeroy technique had higher major morbidity than with electrocoagulation technique (Peto OR 2.87; 95% CI 1.13, 7.25). Postoperative pain was more frequent in the Pomeroy group (Peto OR 3.85; 95% CI 2.91, 5.10). Tubal ring versus electrocoagulation: Post operative pain was more frequently reported in the tubal ring group. No pregnancies were reported. Pomeroy versus Filshie clip: In the trial comparing the two interventions only one pregnancy was reported in the Pomeroy group after follow-up for 24 months. No differences were found when comparing Hulka versus Filshie clip in the only study that compared these two devices (Toplis 1988).

REVIEWER'S CONCLUSIONS

Electrocoagulation was associated with less morbidity when compared with tubal ring and other methods. However the risk of burns to the small bowel might be a serious criticism of the approach. The small sample size and the relative short period of follow-up in these studies limited the power to show clinical or statistical differences for rare outcomes such as failure rates. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.

Development of a novel method of female sterilization: I. The development of a novel method of hysteroscopic sterilization

BACKGROUND AND OBJECTIVES

For more than 100 years, gynecologists have attempted to effect sterilization via a transuterine approach. Our aim was to develop a safe, simple, rapid method of sterilization that could be performed in the outpatient clinic. The authors felt that a tubal screw based on a "self-tapping" screw would be less likely to become dislodged from the uterine cornu with time because multiple backward-pointing threads prevent it from being displaced.

METHODS

During the development of the technique, many changes had to be made to deliver the tubal screw effectively to the uterine cornu. These involved overcoming problems of poor cornual distension before screw application, effecting the requisite deflection toward the uterine cornu, performing the screwing action with a deflected applicator, and finally disimpacting the screw. Changes were made to the tubal screw, hysteroscope, method of uterine distension, method of deflection, screw applicator, and method of disimpaction.

RESULTS AND CONCLUSIONS

The system that appears to be the most efficient consists of a 25F cystoscope with a variable bridge, a 4-mm 30-degree endoscope, and an unsealed spring applicator with bayonet mounting on the screw applied with the use of a pressure bag for uterine distension with saline solution.

Female sterilisations with Filshie clips: What is the risk failure? A retrospective survey of 30 000 applications

OBJECTIVE

To assess the failure rate of Filshie clip sterilisations in Victoria, Australia.

DESIGN

Retrospective study between 1994 and 1998.

SETTING

All specialist gynaecologists practising in the state of Victoria, Australia.

INTERVENTIONS

Questionnaires (up to three) followed by telephone calls if necessary.

MAIN OUTCOME MEASURES

A response rate of 276/277 (99.6%) was obtained. All pregnancies were recorded.

RESULTS

Seventy-three failures were notified from an estimated 30,000 Filshie clip sterilisations carried out in the study period.

CONCLUSIONS

The estimated failure rate of Filshie clip sterilisations in the state of Victoria carried out by specialist gynaecologists was between 2 and 3 per 1000 sterilisation operations.

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.

Two randomized controlled trials comparing the Hulka and Filshie Clips for tubal sterilization

To compare the effectiveness and safety of the Filshie Clip System and Hulka Clip System when applied via minilaparotomy and laparoscopy, we conducted 2 multicenter randomized controlled trials of 2126 women (878 in the minilaparotomy study and 1248 in the laparoscopy study) who received either the Filshie or Hulka Clip. A physician other than the operator evaluated patients postoperatively and again at 1, 6, and 12 months after surgery. We compared the cumulative incidence of pregnancy and the frequency of safety related events for the device groups. Twenty-four month follow-up was planned for a subset of 599 women in the laparoscopy study. One woman who received the Filshie Clip and 6 women who received the Hulka Clip became pregnant within one year. The 12-month life-table pregnancy probability was 1.1 per 1000 women in the Filshie Clip group and 6.9 per 1000 women in the Hulka Clip group. The difference in the risk of pregnancy through 12 months between device groups neared statistical significance (p = 0.06). Among the extended follow-up subset, the 12- and 24-month cumulative pregnancy probabilities were 3.9 and 9.7 per 1000 women for the Filshie Clip group and 11.7 and 28.1 per 1000 women for the Hulka Clip group (p = 0.16 for comparison through 24 months). Both the Filshie and Hulka Clips are effective and safe for use in tubal occlusion.