Hulka Clip Sterilization

One common form of female sterilization is the use of Hulka clips to block the fallopian tubes. The Hulka clip was approved for use in the United States in the 1970’s and was invented in Chapel Hill, North Carolina by Dr. Jaroslav Hulka at the University of North Carolina at Chapel Hill.

The Hulka clip is a small, gold plated stainless steel spring loaded clip. The clip in introduced into the abdominal cavity via a laparoscopic clip applicator. This image shows the open clip in the applicator and the tip of the laparoscope with its fiber optic lighted end. When the clip is placed across the fallopian tube, it is closed and a small spring holds the clip firmly across the tube. The Hulka clip has the advantage of damaging only a very small portion of the fallopian tube- approximately 7mm (the thickness of three quarters stacked on each other).

The Hulka clip causes bilateral tubal occlusion by squeezing a very small portion of the tube. The squeezed portion is deprived of its blood supply and eventually undergoes avascular necrosis (dies and is absorbed by the body). This causes the fallopian tube to be divided in half and the two ends to close up. The Hulka clip is held in place between the two divided tubal segments by a small amount of scar tissue which forms within the clip.

Hulka Clip Reversal

A common misconception is that the Hulka clips can simply be opened to reverse the sterilization process - that the tubes can be unclipped. Unfortunately, tubal ligation reversal for Hulka clips is not that simple. Hulka clip tubal occlusion is reversed by removing the section of the tube with the clip across it and then, using microsurgical techniques, joining the remaining tube segments back together in perfect alignment.

Tubal reversal of Hulka clip tubal occlusion is better than for most other methods of sterilization because such a minimal amount of tube is destroyed in the occlusion process. Approximately 76% of patients at Chapel Hill Tubal Reversal Center become pregnant after a reversal of a Hulka clip sterilization procedure.

Common Misconception About Tied Tubes

Many patients seem to imagine the fallopian tube is like a shoe lace which is tied up like a bow to prevent pregnancy. As tubal ligation reversal specialists, we wish it were that easy- then untying tied tubes would be easier!

‘Tying ones fallopian tubes’ is a common language phrase used to describe several different surgical procedures which result in sterilization (a procedure intended to permanently prevent pregnancy). The more correct medical term is bilateral (both sides) tubal occlusion (closure of the fallopian tube).

There are many different ways to occlude (close) the fallopian tubes: ligation and resection (tying and cutting), clips and rings, and coagulation (burning). No matter how the procedure is done the end result causes the tube to close, heal shut, and prevent sperm from fertilizing an egg.

Tubal Sterilization is Reversible

Many people believe tubal sterilization is permanent and irreversible. Although Hulka clip sterilization is intended to be permanent, this procedure is ideal for tubal reversal. The Chapel Hill Tubal Reversal Center is the one medical facility which specializes in tubal ligation reversal.

We have become experts in reversing all types of tubal ligations- or ‘untying’ tubes that have been ‘tied’!

Submitted by Dr. Charles Monteith

Tying Tubes is Not Like Tying a Shoe Lace

Many patients seem to imagine the fallopian tube is like a shoe lace which is tied up like a bow to prevent pregnancy. As tubal ligation reversal specialists, we wish it were that easy- then untying tied tubes would be easier!

‘Tying fallopian tubes’ is a common language phrase used to describe several different surgical procedures that result in tubal sterilization (a procedure intended to permanently prevent pregnancy). The more correct medical term is bilateral (both sides) tubal occlusion (closure of the fallopian tube).

Tubal Ligation Methods

There are many different ways to occlude (close) the fallopian tubes: ligation and resection (tying and cutting), clips and rings, and coagulation (burning). No matter how the procedure is done the end result causes the tube to close, heal shut, and prevent sperm from fertilizing an egg.

Filshie Clip Tubal Ligation

One common form of laparoscopic (camera) sterilization is the use of Filshie clips to occlude both fallopian tubes. The Filshie clip was approved for use in the United States in the mid 1990’s. The Filshie clip is a small titanium clip which is lined with a thin silicone cushion. The clip was an improvement over the Yoon Falope Ring and the Hulka Clip because it was as easy to apply with less risk of operative complications. The clip also has the advantage of destroying only a very small portion of the fallopian tube- approximately 4mm (approximately the thickness of two quarters stacked on each other). The adjacent tube is not affected. The majority of Filshie clips placed in the United States are done by laparoscopic surgery; however, there is a growing trend to use them for tubal occlusion at the time of cesarean delivery (c-section).

The Filshie clip causes bilateral tubal occlusion by squeezing a very small portion of the tube. The squeezed portion is deprived of its blood supply and eventually undergoes avascular necrosis (dies and is absorbed by the body). This causes the fallopian tube to be divided in half and the two ends to close up. The Filshie clip is held in place (in between the two divided ends) by a small amount of scar tissue which forms over the clip.

A common misconception is that the Filshie clips can simply be removed to reverse the sterilization process- that the tubes can be unclipped. Unfortunately, tubal ligation reversal for Filshie clips is not that simple. Filshie clip tubal occlusion is reversed by removing the clips and using microsurgical techniques to open the closed ends and join the tube segments back together in perfect alignment.

The reversal of Filshie clip tubal occlusion is usually technically easier than some other methods of sterilization because such a minimal amount of tube is destroyed in the occlusion process.

Approximately 76% of patients at Chapel Hill Tubal Reversal Center become pregnant after a reversal of a Filshie clip sterilization procedure.

Tubal Sterilization Can Be Reversed

Many people believe tubal sterilization is permanent and irreversible. Although Filshie clip sterilization is intended to be permanent, this procedure can be reversed. Chapel Hill Tubal Reversal Center is the one medical facility that specializes in tubal ligation reversal.

We have become experts in reversing all types of tubal ligations- or ‘untying’ tubes that have been ‘tied’!

Submitted by Dr. Charles Monteith

Anesthesia for Tubal Ligation Reversal

Submitted by Pam Mills, CRNA

Being part of the anesthesia care team at Chapel Hill Tubal Reversal Center has given me the opportunity to work one on one with tubal reversal patients in an outpatient setting and to assure they receive the best medical care they have ever experienced.

For anesthesia purposes, we record pain scores and the incidence of postoperative nausea for all of our patients. We conduct comprehensive reviews of our data and implement changes to our anesthesia protocol, if necessary. This performance improvement activity is the beauty of working in a small private setting.

All of our patients receive individual attention and care. We have had patients tell us, “This is the first time in my life I have not been sick after anesthesia!” and “This was the easiest anesthesia I have ever had!”

I can’t think of anything more rewarding than to have helped our patients have a safe and pleasant experience while they are here for their tubal ligation reversal procedures.

Personalized Anesthesia Plan

If a patient tells me that she experienced nausea after an anesthetic in the past, I sit down with her and discuss our anesthesia plan and how it is designed to optimize her comfort and well being during her postoperative recovery. I want her to be confident that she will be well taken care of and that we will do everything in our power to make this anesthetic different from what she experienced previously. Our patients receive two medications through their IV to prevent nausea, and for patients with special needs I give what is is fondly referred to as my “special cocktail”. This cocktail has a combination of two additional anti-nausea medications, also given through the IV before the patient wakes up. This covers all the possible trigger centers in the body that can cause nausea.

Power of Positive Thinking

I usually end our discussion of postoperative nausea by telling the patient and family member that this will be the last we will mention of this subject, as I am a firm believer in planting the seed of positive thought. So from then on I want them to focus on positive thinking, knowing that she will be well taken care of and anticipating that she will wake up feeling well and free of pain or nausea.

Patient Care at Chapel Hill Tubal Reversal Center

Our dedication to patient care and outcome is evident in our patient follow up care. Every patient is entered into our computerized database. This database includes information from the day of surgery, their postoperative recovery, follow upcontacts by our nurses, as well as every pregnancy following the tubal reversal procedure through to its outcome. There is no better place for women to have tubal reversal surgery than at Chapel Hill Tubal Reversal Center. Our anesthesia staff goes to extra lengths to ensure the patient’s safety, comfort, and sense of well-being during and after the tubal reversal procedure.

PTLS Diagnosis and Tests

An email message received today about Post Tubal Ligation Syndrome (PTLS) from a patient who is scheduled for tubal reversal next month prompted this blog topic. I thought it would provide helpful information to others with similar concerns.

“My problem is horrible PTLS. I had my tubes tied in 05 at the time of my 3rd C-section. I understand that PTLS is not widely accepted or recognized in the medical community as a true syndrome or diagnosis, but could I expect to see something supporting that diagnosis in any blood work or hormone tests? Would it be normal to see abnormal hormone levels to some degree in support of this diagnosis or is it possible that all my levels would be ok but that the disruption in the flow of blood between ovaries and uterus could cause all of my symptoms and simply not show changes in hormone levels? Also, are there specific hormone tests I can have my ob/gyn check?

I only came across all this info on the net while desperately searching for answers to my growing list of symptoms that I never thought were related. This is very nerve wracking and exhausting. Three years is a long time and I look forward to this journey coming to an end and new one beginning, but I have so many questions and I was hoping you could steer me in the right direction so I can have any other diagnostics tests that may be helpful to my cause.”

Dr. Berger’s Response

One of the reasons that PTLS is not recognized as a true syndrome by most physicians is that there is no specific diagnostic test that is correlated with symptoms. If you search through the medical literature, you will find many studies with conflicting results. For example, you can do a search using Google Scholar for “hormones post tubal ligation syndrome” to review results from some recent medical studies.

Diagnostic Codes

There is no diagnostic code for Post Tubal Ligation Syndrome in the International Classification of Diseases (ICD). Without a specific diagnostic code, insurance companies do not provide reimbursement for testing or treatment. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) does have other diagnostic codes that can be used, depending upon the symptoms being experienced:

• ICD-9-CM #625.0  Dyspareunia - Painful sexual intercourse.
• ICD-9-CM #625.3  Dysmenorrhea - Painful menstruation.
• ICD-9-CM #625.4  Premenstrual tension syndromes -
  Distressing physical, psychologic, or behavioral changes that occur during the luteal phase of the menstrual cycle. Symptoms of PMS are diverse (such as pain, water-retention, anxiety, cravings, and depression) and they diminish markedly 2 or 3 days after the initiation of menses.
• ICD-9-CM #626.2  Menorrhagia  - Excessive menstruation.
• ICD-9-CM #626.6  Metrorrhagia - Irregular uterine bleeding.
• ICD-9-CM #627.0  Premenopausal menorrhagia
• ICD-9-CM #626.8  Disorders of menstruation, other

Insurance Coverage

Insurance companies do not recognize PTLS as a medical entity. Depending upon the symptoms you have, your doctor could use one or more of these diagnostic codes. The specific tests that may be appropriate will depend on your symptoms. For example, if you have pelvic pain, then ultrasound examination would be appropriate as part of an evaluation for pain. Abnormal menstrual bleeding would appropriately involve hormonal assays (FSH, LH, estradiol, progesterone). Based on the results of any preoperative testing, a diagnostic code could be listed on your operative report as a preoperative and postoperative diagnosis. This might influence the insurance company regarding possible reimbursement for tubal reversal surgery. Read your insurance policy carefully. If it specifically states that tubal reversal is not a covered benefit, no matter what information is sent to the insurance company, there will be no reimbursement. If the policy does not specify that tubal reversal is excluded, then there may be a possibility of getting reimbursement from your insurance carrier.

More Information about Post Tubal Ligation Syndrome

Post Tubal Ligation Syndrome is written about on many pages of the Chapel Hill Tubal Reversal Center website. There are also many discussions about PTLS on the Tubal Reversal Message Board. Another excellent source of information is Post Tubal Ligation Syndrome News.

Tying Tubes

Many people seem to imagine the fallopian tube is like a shoe lace that is tied in a bow to prevent pregnancy. As a tubal ligation reversal specialist, I wish it were that simple- then reversing tied tubes would be a whole lot easier!

Perhaps a well meaning doctor may have told a patient one day, “I am going to tie your tubes so you don’t get pregnant.” Maybe the doctor wrote a letter to a medical journal explaining the procedure and then the terminology stuck. More likely, a reporter may have simplified the terminology for the surgical procedure of tubal ligation to make a catchy title for an article. Others may then have started using the term “tying tubes” to quickly explain a complex procedure. These explanations often have a long life span and make their way into common language.

The more accurate terminology is bilateral tubal occlusion (closure of both fallopian tubes) which results in sterilization (not being able to conceive). There are many ways to perform bilateral tubal occlusion. The most common tubal sterilization procedure is performed at the time of cesearean delivery (c-section) or immediately after having a baby. It does involve tying the tubes with a suture - but then also cutting out a segment of healthy tube, resulting in closure of the tube as it heals. The suture then dissolves. The intial suture tying is most likely where the phrase ‘tying tubes’ came from.

Another common method is to burn the tubes with electrical energy (electrocoagulation). This is usually done by laparoscopic surgery and is usually done remote from pregnancy. Lastly, there are many devices- clips and bands - which can close off the tubes and cause a portion of the tube to be destroyed.

No matter how the procedure is done, the end result is obstruction of the fallopian tube that prevents pregnancy.

Many people believe that tubal sterilization is irreversible. Although bilateral tubal occlusion is intended to be permanent, the procedure can be reversed. Chapel Hill Tubal Reversal Center is the one medical facility that specializes exclusively in reversal of tubal ligation. We have become tubal ligation reversal experts………experts at untying tied tubes!

Submitted by Dr. Charles Monteith