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 as simple as opening the clips. 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

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

Is There a Simple Procedure to Untie Tubes?

Women who have had their tubes tied and then want to get tubes untied often ask if there is a simple procedure that permits pregnancy after tubes tied. Often they envision a tubal ligation as if there is a bow tied around the tubes that can be simply untied, like one unties a shoelace. This is actually not the case. The common term “tying tubes” simplifies what is a tubal ligation - or tubal sterilization - is.

How Tubes are “Tied”

Pomeroy Tubal Ligation

Tied and Cut

Final Result

The most common type of tubal ligation involves putting a surgical ligature (or tie) around a loop of the fallopian tube and then cutting off the segment that has been ligated. The two tubal segments separate from each other. This is the Pomeroy technique, first describe by Dr. Ralph Pomery. Some doctors burn the ends of the tubes that have been cut and may use the term “modified” Pomeroy procedure in their operative report.

Another common type of ligation/resection procedure is the Parkland tubal ligation. With this techniqe, two ligatures are placed around the tube at a distance from each other and the portion of the fallopian tube in between the ligatures is resected (cut out). There are many other variations of the ligation and resection method of tubal ligation.

Tubal sterilization can also be performed by burning the tubes. This may be done with electocoagulation (coagulation, cautery, or cauterization) or with thermal coagulation. There are also variations with the coagulation methods of tubal ligation, such as the use of monopolar or bipolar coagulators, and the number of sites burned and for how long they are burned. The greater the number and the longer coagulator is applied to the tube, the greater the amount of damage.

A third method of female sterilization involves simply blocking or obstructing the tube with clips or rings. In general, these tend to cause the least amount of damage to the tube. Of all tubal ligation techniques, the tubal clip (Filshie clip or Hulka clip) is the least damaging and the one that consistenly gives the best results when the tubes are “untied” or repaired.

Essure is another new tubal sterilization procedure. This does not require surgery, but it is the least reversible method for women wanting kids after tubal ligation.

Dr. Berger’s Comment

This summary is to help women who want to get their tubes untied. The first thing to know is what tying tubes actually means. It is not as simple as placing a string around the tube that can later be untied. Contrary to what some people think, tubes don’t become untied by themselves after a certain length of time. With this basic information about the fallopian tube and tubal ligation methods in mind, I will explain how reversal of tubal ligation is done in the next topic Tubal Reversal Blog - How to Get Tubes Untied: Reverse Tubal Ligation.

Past topics in the Tubal Reversal Blog include posts and comments about patient care at Chapel Hill Tubal Reversal Center. This topic summarizes important articles about tubal ligation and tubal reversal reported in the news during 2007.

Sterilization is Most Popular Family Planning Method
Approximately 10 million American women use the pill for contraception, while sterilization has been chosen by 15 million men and women.

One In Five Women Regret Decision For Tubal Ligation
One in five women under age 30 who undergo tubal sterilization later regret the procedure, despite the number of children they have.

Is Sterilization the Best Contraception Choice?
Women requesting a tubal ligation should be counseled regarding other long-term, reversible methods of contraception and informed that vasectomy is safer and more effective than tubal ligation.

Tubal Ligation Counseling Issues
Counseling about tubal ligation should include permanence of the method, possibility of future regret, and information about the specific techniques of tubal sterilization.

Relationship Conflict Before Sterilization
Women whose relationship was marked by substantial conflict before they underwent tubal ligation were most likely to regret the decision.

Young Age, Prodding Partner and Sterilization Regret
Young age and a prodding partner are risk factors indicating that a woman undergoing sterilization may later regret her decision.

Tubal Reversal Among Overweight Women
Overweight women’s chances of becoming pregnant after tubal reversal improve when they lose weight.

Dr. Berger’s Comment

These news reports touch on some of the issues patients talk about when they come to Chapel Hill Tubal Reversal Center for tubal sterilization reversal. The popularity of tubal ligation, and the fact that many women regret their decision to have a tubal ligation, are well documented. Young age and marital conflict are risk indicators for subsequent regret. Before performing a tubal ligation, doctors should ensure that the implications of ending childbearing potential are clearly understood and discuss vasectomy as an alternative permanent method of birth control. Women undergoing tubal reversal who are overweight should be aware that losing weight will improve their chances of becoming pregnant again.

What is Essure?

Essure is a permanent birth control device that has recently become available as an alternative to traditional tubal ligation methods. The spring-like device is inserted through the uterine cavity into the tubal openings using a hysteroscope. This can be done as an in-office procedure. The device expands to fill the tubal opening and then becomes scarred into place, forming a barrier so that sperm cannot reach the egg. Because of the scar formation, it cannot be pulled out of the tube. It is advertised by the manufacturer as a permanent method of birth control. In this respect, it is similar to other tubal ligation methods that are considered by most doctors to be permanent.

Here is a link to an online video animation of the placement of the Essure device into the fallopian tubes.

Is Tubal Reversal Possible For The Essure Device?

I perform 4 tubal reversal procedures each day at Chapel Hill Tubal Reversal Center. The women who come here have all varieties of tubal ligation methods. Today, one of the patients had the Essure sterilization method. When she chose this form of tubal sterilization, she was unaware that she would become remarried and want to be able to try to have a child with her new husband.

Although I could not find any previous references regarding attempts to reverse the Essure procedure, I agreed to attempt to perform a reversal for her. The way I did this was to cut the device out of the uterine muscle and then implant the remaining fallopian tube into the uterine cavity through a new opening in the uterus. This procedure is called tubouterine implantation.

The reason I removed the device was that part of the metal spring projects into the uterine cavity. If a pregnancy were to occur with the device in place, this could be harmful to the pregnancy. To my knowledge, this is the first time that the Essure sterilization procedure has been reversed.

Tubal Ligation by Falope Ring and Hulka Clip

The Falope ring and Hulka clip are occlusive methods of tubal ligation. They block the fallopian tubes, but no tubal segments are clamped, removed, or burned. The Falope ring is also referred to as the tubal ring or tubal band. It constricts a segment of the fallopian tube very tightly, like an extra strong rubber band.

The Hulka clip is a miniature clamp placed across a very small (2-3 mm) segment of the fallopian tube. Another clip method besides the Hulka clip is the Filshie clip. The clips are similar except that the Hulka clip is made out of silastic and the Filshie clip is made out of metal. Occlusive methods of tubal ligation are predictably the best in terms of reversal since they damage such a tiny segment of the fallopian tube.

In contrast to the Pomeroy method, these occlusive devices are applied through a laparoscope. (Laparoscopy involves making a small incision below the belly button.) Many doctors prefer to apply tubal rings or clips when performing a tubal ligation on young women in recognition of the greater likelihood that a tubal reversal may be wanted in the future. Studies have shown that tubal ligation regret and the desire for tubal ligation reversal is more common when a tubal sterilization is performed among women in the twenties than among older women.

Tubal Clip and Ring Reversal Success

Each year Chapel Hill Tubal Reversal Center publishes current statistics about pregnancy rates and pregnancy outcomes among all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal rings or clips shown in the table below is from our Tubal Reversal Pregnancy Study Report 2007.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after tubal reversal for women with clips or rings is 76% for patients at Chapel Hill Tubal Reversal Center. In the table below, the first column shows ages groups. The second column shows the number of women in each age group who had a tubal reversal. The third column shows the number of women in that group who became pregnant and the last column shows the percentage of women who became pregnant (the pregnancy rate) after their reversal procedures.

Pregnancy Rates After Tubal Reversal of Clips/Rings

Highest Pregnancy Rates After Tubal Reversal

The highest tubal reversal pregnancy rates are seen among women who have reversal of tubal clips or tubal rings. For women in their twenties, the pregnancy rate was 87%. The pregnancy rate ranged from 83% to 73% for women in their thirties. Among women age 40 or older, the pregnancy rate was significantly lower (47%), reflecting the decline in natural fertility with age. These pregnancy rates among our tubal reversal patients are similar to the pregnancy rates for women who have never had a tubal ligation to begin with.