Rationale: Pregnancy is considered a category D (delay the procedure until the condition is corrected) by the WHO for performing female sterilization. While medical contraindications do not exist for performing a female sterilization during early pregnancy, the perception is that the sterilization procedure has failed. Clients should be refused sterilization if an early pregnancy cannot be ruled out (302).

The procedure should be delayed in the presence of certain conditions (see WHO Eligibility Criteria).

The procedure should be delayed in the presence of certain conditions (see WHO Eligibility Criteria).

Sterilization can also be performed postpartum once the uterus is fully involuted.

In the context of postabortion care, where it is possible that an unsafe abortion has occurred, female sterilization should not be performed unless the provider is sure the woman is free from infection.

Rationale: From the surgical perspective, minilaparotomy performed within 48 hours after vaginal or cesarean delivery is easier than and as safe and effective as interval sterilization. Because the uterus is enlarged immediately postpartum, the fallopian tubes are nearer the abdominal wall and can be reached easily during the first 48 hours after delivery. Approximately 2 days postpartum the uterus begins to involute and by 2 weeks is within the true pelvis. Thus, after 48 hours postpartum, more care is required if sterilization is to be performed since the uterus becomes less accessible from the subumbilical incision and its position in the abdomen may be difficult to ascertain. The uterus is still accessible for up to 7 days but may require a slightly lower incision (49, 314).

It has been recent practice to avoid doing postpartum female sterilization after 48 hours because of a concern about increased infection. Because bacteria are present in the endometrial cavity and fallopian tubes, prophylactic antibiotics are recommended when female sterilization is performed beyond postpartum day 3 (169).

Severe pre-eclampsia/eclampsia, premature rupture of membranes, sepsis or indication of infection, severe hemorrhage, and severe trauma to the genital tract or uterine rupture or perforation are contraindications to female sterilization, and the procedure should be delayed until the condition is resolved (302).

The uterus is usually fully involuted 4 weeks after delivery, although it may take 6 weeks or longer in some cases. For women who are not breastfeeding and are therefore at some risk of pregnancy before 6 weeks, if the uterus is fully involuted female sterilization at 4 weeks postpartum can be safely provided. If the uterus is not fully involuted, this may be a sign of infection or incomplete resolution of postpartum healing, and female sterilization should be delayed (121).

In the absence of complications, female sterilization can be performed at the same time as the abortion (302).

If the woman intends to breastfeed her infant, local anesthesia is preferred over general anesthesia to minimize interruption of the early breastfeeding pattern and infant exposure to the anesthetic agent.

General anesthesia may effect lactation by delaying the start of breastfeeding while the mother recuperates from the anesthesia and by hampering the infant's attempts to feed if the infant has ingested some of the anesthetic agent in the milk. The negative effect is more pronounced when the sterilization is not performed immediately after delivery (142, 143).

Rationale: Age at time of sterilization has been found to be a risk factor for regret in both women and men. Wilcox et al., in a prospective study based on 7,590 US women followed up for 5 years, found that women under 30 years of age at sterilization were 2 to 3 times more likely to report regret than those sterilized between 30 and 35. This effect was independent of number of living children or marital status at the time of sterilization (295). Young age has also been found to be a major factor in other US studies and in studies of women in Canada and Puerto Rico (26, 116, 182).

Parity has often been discussed as a risk factor for regret in women. Several major studies have not found parity to be a significant predictor of regret. However, some experts suspect that parity may still be an important predictor of regret in some cultures (26, 116, 171, 182, 217, 295).

However, if it does not pose a barrier to access and the woman is using another contraceptive method so that she is not at risk of pregnancy, it is often beneficial for the woman to have time to think about her decision.

For cases associated with delivery (postvaginal delivery, postpartum, or concurrent with cesarean section), it is recommended that counseling occur well in advance of delivery, wherever possible, to minimize the chances of regret following the decision. If counseling cannot be provided in the antenatal period, it may be provided in the immediate postpartum period once the woman is past the major stress of labor and delivery and has no residual effects of anesthesia or sedatives.

Rationale: For postpartum minilaparotomy, counseling should take place well in advance of delivery, at a time when the woman is under minimal stress. During counseling, the woman should be told that if she changes her mind or if the condition of the baby is unstable, she can choose not to have the sterilization after giving birth. If she will give birth away from the hospital, she should be counseled that she must come to the hospital within 7 days (preferably within 48 hours) or wait until at least 4 to 6 weeks after delivery for an interval procedure. If family planning counseling has not been provided during the antepartum period, it should be included in postpartum services (199).

The changes reported by these women seem to be related to aging or stopping the use of oral contraceptives, not to the procedure.

Rationale: For many years there has been controversy over whether or not a "post-female-sterilization syndrome" truly exists. The varying definitions of post-female-sterilization syndrome usually refer to menstrual symptoms such as dysmenorrhea, heavy bleeding, or spotting, and changes in cycle length or regularity. It has also been suggested that methods of occlusion resulting in more extensive damage to the fallopian tubes and mesosalpinx may be more likely to cause subsequent changes in menstrual function.

Some criticism faulted early studies on menstrual irregularities following sterilization for a failure to account for other factors leading to a change in menstrual function following sterilization such as presterilization use of oral contraceptives possibly masking underlying menstrual dysfunction. Recent prospective studies that accounted for these confounding factors have failed to find a significant difference in the change in menstrual function between sterilized and nonsterilized women over time.

Most studies of menstrual change following sterilization have had periods of follow-up for 1 to 2 years and have found no increase in risk of menstrual change. Studies with follow-up periods longer than 1 year have been inconsistent in their findings (56, 234).

Studies looking at laboratory determinations of hormone levels as a possible mechanism for the post-female-sterilization syndrome have yielded little useful information. Many studies compare women undergoing sterilization with controls but do not measure the subjects' hormone levels preoperatively. Studies that did measure such levels preoperatively found no changes following sterilization (but these studies involved small numbers of women) (3, 95, 226).

Female sterilization is the most effective long-term family planning method other than vasectomy. Female sterilization is particularly effective when performed by partial removal of the tube, as with minilaparotomy, either:

• Immediately postpartum, or
• At 6 or more weeks after delivery (interval sterilization).

Rationale: Female sterilization is the only permanent female family planning method. Annual pregnancy rates for minilaparotomy using partial salpingectomy, commonly the Pomeroy and Parkland techniques, are very low, but when failure occurs, it is most often in the first or second years after surgery. Rarely do pregnancies occur after 5 years.

The best data come from a long-term US study (216). This study reports that the cumulative pregnancy rates during the first 5 years and for years 6 through 10 per 100 women are:

• For postpartum partial salpingectomy, 0.6 and 0.1 per 100 women, respectively;
• For laparoscopic silicone bands, 1.0 and 0.8.

Experts assume that the extremely low pregnancy rates in years 6 through 10 will continue through years 11-20, which is very important for women wanting no more children. Because pregnancies are rare events following female sterilization, accurate pregnancy rates are difficult to determine from international data sources such as the Demographic and Health Surveys (DHS) and therefore are not routinely reported with pregnancy rates for other methods (196, 216, 301).

Recommendation: The 10-year cumulative pregnancy rate is 1.8% for tubal sterilization by laparoscopy using silicone bands.

Silicone bands are the most common laparoscopic female sterilization method outside North America and Western Europe. Female sterilization by laparoscopy using silicone bands is equally effective as interval minilaparotomy techniques.

Rationale: Laparoscopic female sterilization by spring clip and bipolar electrocoagulation result in higher cumulative 10-year pregnancy rates, 3.7 and 2.5 per 100 women, respectively (whereas the 10-year pregnancy rate for a postpartum partial salpingectomy is 0.8 per 100 women). However, these laparoscopic occlusion techniques are used infrequently outside North America and Western Europe (216).

Recommendation: The 10-year cumulative ectopic pregnancy rate is 0.73% for all methods of tubal sterilization combined.

Rationale: The 10-year cumulative ectopic pregnancy rates were higher in women who were younger than 30 at the time of the sterilization compared with women who were 30 or older at the time of the procedure, and in women who were sterilized by bipolar coagulation compared with women sterilized by any other method (349).

Rationale: Various types of doctors, including general medical practitioners, general surgeons, and other specialists (such as obstetrician-gynecologists), can receive training to perform minilaparotomy, as can paramedical professionals (such as midwives) who routinely perform surgery in a country. It is important that candidates selected for training be interested in and supportive of voluntary sterilization as a family planning choice. In addition, trainees who have demonstrated their surgical ability and who have prior experience in abdominal surgery are suitable to be trained in minilaparotomy and management of surgical complications. Those with no or minimal previous abdominal surgery experience may be safely trained to competently perform minilaparotomy in settings where surgical backup is available on site or by referral (13, 299).

The woman should be encouraged to come back promptly if she has any problems (such as fever, pain, bleeding, or pus) or at any time if she has questions or concerns.

Rationale: The follow-up examination should take place between 7 and 14 days after surgery. If nonabsorbable sutures were used, removal after 7 days increases the risk of infection (301).

There is no medical benefit to routine long-term follow-up, although women should be encouraged to seek medical care for general health reasons. In addition, women should receive counseling on warning signs that would necessitate a return to the provider.

Although some studies have reported high success rates, the live birth rates are lower than the "success" rates reported because "success" is often defined as an intrauterine pregnancy and includes both births and miscarriages. Only a small fraction of the total number of women who request reversal are likely to have a successful reversal procedure.

Rationale: Reversing sterilization is a complex and expensive procedure (68, 232).

Rouzi et al. found that age and average tubal length were significant factors in predicting success of sterilization reversals (233). Other predictive factors are the type of sterilization procedure and surgeon's experience.