Understanding Tubal Ligation Clips: Imaging, Risks, Migration, and Management

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 Understanding Tubal Ligation Clips: Imaging, Risks, Migration, and Management

Keywords: tubal ligation clips, Filshie clip migration, Hulka clip imaging, chronic abdominal pain, radiology of tubal clips, tubal ligation complications, surgical sterilization clips

1. Introduction

Tubal ligation clips (commonly Filshie clips or Hulka clips) are small metallic or plastic clips applied to the fallopian tubes during laparoscopic sterilization. While widely accepted for permanent contraception, these devices pose unique clinical and imaging considerations. This expert‑level column explores their radiologic appearance, typical complications such as clip migration, symptom profiles, and management strategies.

2. What Are Tubal Ligation Clips?

In laparoscopic tubal ligation, Filshie clips—titanium with a silicone lining—are applied bilaterally to occlude the fallopian tubes. Alternatively, Hulka clips, spring‑loaded plastic with a gold spring lock, offer another mechanical occlusion option.

Clinically, tubal ligation using clips is considered more convenient, safe, and quicker than bipolar electrocoagulation—many studies report shorter operative time and hospitalization with similar early complication rates.

3. Radiological Appearance

On plain abdominal or pelvic radiographs, tubal ligation clips appear as small dense metallic staples or spring clips, commonly located in the pelvis adjacent to the expected location of the fallopian tubes. They may appear bilaterally symmetric, but can also be eccentrically located if dropped during surgery or migrated 

Figure 1: Abdominal plain radiograph showing bilateral tubal ligation clips, one within the pelvis and one migrated to the right upper quadrant

Further imaging—CT or pelvic radiography—confirms location and assists in evaluating migration or complications.

4. Complications: Migration and Clinical Presentation

4.1 Frequency of Migration

Up to 25 % of patients with Filshie clips may experience clip migration, although only 0.1–0.6 % eventually develop symptomatic complications or extrusion

4.2 Common Migration Sites

Migrated clips have been reported in:

  • Peritoneal cavity (Douglas pouch or paracolic gutters)

  • Abdominal wall or inguinal region

  • Bladder

  • Vagina or anal canal (rare extrusion)

4.3 Time Course

Symptom onset ranges from 6 weeks up to 40 years after sterilization, with cases reported decades later

4.4 Clinical Symptoms

Patients may present with:

  • Chronic unexplained abdominal or pelvic pain

  • Recurrent abscesses or fistulation

  • Gross hematuria (when the clip migrates into the bladder and forms a calculus)

4.5 Rare Extrusion

Rare instances exist where Hulka clips are spontaneously expelled via the vagina or anus through fistulous tracts years post‑procedure.

5. Diagnosis

5.1 Imaging Modalities

  • Plain radiographs (AXR): first‑line to detect radiopaque clips.

  • CT scan: useful for assessing relations to adjacent organs and evaluating complications.

  • Ultrasound or cystoscopy: indicated when the clip is intra‑bladder or associated with urinary symptoms.

5.2 Clinical History

A detailed history, including remote tubal ligation, onset of pain, urinary or GI symptoms, and imaging findings, helps guide diagnosis. Clinicians should maintain a high index of suspicion when evaluating unexplained abscesses or foreign body symptoms in women with prior sterilization.

6. Management

6.1 Conservative vs Surgical

  • Asymptomatic migrated clips may be managed conservatively with observation.

  • Symptomatic cases often require laparoscopic surgical removal or drainage of abscesses.

  • Bladder migration cases may necessitate cystolithotripsy and clip removal via cystoscopy

6.2 Informed Consent & Counseling

Patients undergoing tubal ligation should be counseled about possible late complications, including clip migration, chronic pain, and rare extrusion. Awareness helps mitigate medico‑legal risks.

7. Procedural Advantages of Clip Ligation

Compared to alternative sterilization, Filshie clips present:

  • Easier and safer application

  • Shorter operative and hospitalization time

  • Minimal early complications

Medical literature recognizes this technique as effective and widely used globally. Clip sterilization accounts for 10–40 % of global female sterilizations

References

  1. S. Sharma, R. Martyniak, and V. Khokhotva, “Migrated Tubal Ligation (Filshie) Clip as an Uncommon Cause of Chronic Abdominal Pain,” Case Reports in Surgery, vol. 2020, Article ID 4809859, 2020. doi:10.1155/2020/4809859. RadiopaediaGriffin Purnell

  2. A. S. Lakha et al., “Migrated sterilisation clips presenting in abscesses or bladder stones,” Surgical Case Reports, vol. 10, no 143, 2024. SpringerOpen

  3. BMJ Case Reports, “Spontaneous Expulsion of Tubal Ligation Clips: A Case Report,” 2009. ScienceDirect

  4. Radiopaedia.org, “Tubal ligation clips – case study,” 2025. RadiopaediaRadiopaedia

  5. Radiopaedia.org, “Hulka clips – case study,” 2012. Radiopaedia

  6. J. Amidi and M. Naseri, “A comparison of bipolar electrocoagulation and Filshie‑Clips in Tubal Ligation,” J. Inflamm. Dis., vol. 3, no 2, e154651, 2024. Brieflands

  7. Systematic review group, “A systematic review of long‑term complications of mechanical tubal occlusion,” Eur. J. Obstet. Gynecol. Reprod. Biol., 2023. ScienceDirectEjog

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