Failures of laparoscopic sterilization by Hulka-Clemens clips.

PIP: The reasons for failure in a series of 544 laparoscopic sterilizations by Hulka-Clemens clips are analyzed. Patients were divided into 2 groups: 1) 327 women sterilized by clips, and 2) 217 women sterilized with clips simultaneous to suction abortion. Most patients were 31-41 years of age. 10 pregnancies were observed in the 4-12 month follow-up, most of which occurred 2-4 months after clip application. None of the pregnancies were ectopic. The higher failure rate in group 2 (7%) compared to group 1 (1.83%) is due to the larger uterine size in the pregnant women. Most failures were attributable to a lack of technical training on the part of operators. In most cases, the clips were applied to a structure other than the tube: round ligament (3 cases), fimbriae (2 cases), utero-ovarian ligament (1 case), twisted spring (3 cases). The cause for failure remains unknown in 1 case. Compared with other sterilization methods (e.g., diathermic coagulation, Yoon ring), the Hulka-Clemens clip procedure has a low rate of method failure. Other studies have noted the following reasons for failure: material, application in already pregnant patients, incomplete nipping of the tubal lumen, application on another structure, and decrease of pressure on the jaws of the clip. Subsequent pregnancies with this method can be avoided by attention to optimal presentation of the uterus during the procedure to facilitate tubal cupping, and adequate supervision when the procedure is done by an inexperienced operator.^ieng

[The 'lost' intra-uterine contraceptive device (author's transl)]. / Le dispositif intra-utérin "disparu"

The authors report five cases of lost intra-uterine devices, which means that the threads were not visible at the external os of the cervix. This gives them an opportunity to review the literature and to conclude the following: 1. Ultra-sound is the treatment of choice to find the position of the IUD that has been lost, whether is is intra- or extra-uterine. 2. In doubtful cases an antero-posterior and a lateral hysterogram makes it possible to determine the relative position of the IUD to the uterine cavity. Laparoscopy gives useful complementary information. 3. If the IUD is intra-uterine, either totally so or partially, the treatment of choice is to remove it under hysteroscopic control. 4. Where perforation has occurred and the IUD has only entered incompletely into the pelvis, it is possible to pull it out under hysteroscopic control through the vagina if laparoscopy has demonstrated that there are no local adhesions attaching it to neighbouring organs. 5. Where perforation has been complete, laparotomy is preferable to laparoscopy as a technique to recover the lost IUD, in particular when this is a copper one. 6. Perforations occur particularly when the IUDs are inserted post-partum.