A 35-year-old woman with three previous cesarean sections requests permanent contraception. She is counselled on bilateral tubal ligation techniques. Which method provides the highest long-term failure rate, and what is its mechanism of failure?

• A Pomeroy technique; recanalisation of tubal stump ends
• B Hulka-Clemens spring clip; spring mechanism failure with partial tube occlusion ✓
• C Filshie clip application; incomplete occlusion due to clip misapplication on a thick tube
• D Electrocoagulation (unipolar); extended thermal injury reduces later recanalisation

Explanation

The Hulka spring clip has the highest long-term failure rate among mechanical occlusion methods (10-year cumulative failure rate ~3.7 per 1,000 in the US CREST study, compared to ~0.7 per 1,000 for Filshie clip and ~0.75 per 1,000 for silicone band). The spring mechanism may not fully close on tubes of variable diameter or thickness, resulting in incomplete occlusion and leaving a segment for recanalisation. Pomeroy technique (excision of a knuckle of tube) has a very low failure rate. Unipolar electrocoagulation actually has a higher recanalisation risk than bipolar in the long-term due to extensive tissue destruction causing less predictable tissue response, but the CREST data confirm the Hulka clip as having the highest mechanical failure rate among clip methods.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.