When to Perform the Procedure

Important: if there is no medical reason to delay, a woman can have the female sterilization procedure any time she wants if it is reasonably certain she is not pregnant. To be reasonably certain she is not pregnant, use the Pregnancy checklist.

Ensuring Informed Choice

Important: a friendly counsellor who listens to a woman’s concerns, answers her questions, and gives clear, practical information about the procedure—especially its permanence—will help a woman make an informed choice and be a successful and satisfied user, without later regret (see Because Sterilization Is Permanent, below). Involving her partner in counselling can be helpful but is not required.

Counselling must cover all 6 points of informed consent. In some programs the client and the counsellor also sign an informed consent form. To give informed consent to sterilization, the client must understand the following points:

1. Temporary contraceptives also are available to the client.

2. Voluntary sterilization is a surgical procedure.

3. There are certain risks of the procedure as well as benefits. (Both risks and benefits must be explained in a way that the client can understand.)

4. If successful, the procedure will prevent the client from ever having any more children.

5. The procedure is considered permanent and probably cannot be reversed.

6. The client can decide against the procedure at any time before it takes place (without losing rights to other medical, health, or other services or benefits).

Because Sterilization Is Permanent

A woman or man considering sterilization should think carefully:

“Could I want more children in the future?”

Health care providers can help the client think about this question and make an informed choice. If the answer is “Yes, I could want more children,” another family planning method would be a better choice.

Asking questions can help. The provider might ask:

• “Do you want to have any more children in the future?”
• “If not, do you think you could change your mind later? What might change your mind? For example, suppose one of your children died?”
• “Suppose you lost your spouse, and you married again?”
• “Does your partner want more children in the future?”

Clients who cannot answer these questions may need encouragement to think further about their decisions about sterilization.

In general, people most likely to regret sterilization:

• Are young
• Have few or no children
• Have just lost a child
• Are not married
• Are having marital problems
• Have a partner who opposes sterilization

None of these characteristics rules out sterilization, but health care providers should make especially sure that people with these characteristics make informed, thoughtful choices.

Also, for a woman, just after delivery or abortion is a convenient and safe time for voluntary sterilization, but women sterilized at this time may be more likely to regret it later. Thorough counselling during pregnancy and a decision made before labor and delivery help to avoid regrets.

The Decision About Sterilization Belongs to the Client Alone

A man or woman may consult a partner and others about the decision to have sterilization and may consider their views, but the decision cannot be made for them by a partner, another family member, a health care provider, a community leader, or anyone else.

Family planning providers have a duty to make sure that the decision for or against sterilization is made by the client and is not pressured or forced by anyone. 

Performing the sterilization procedure

Explaining the Procedure

A woman who has chosen female sterilization needs to know what will happen during the procedure. The following description can help explain the procedure to her. Learning to perform female sterilization takes training and practice under direct supervision. Therefore, this description is a summary and not detailed instructions.

(The description below is for procedures done more than 6 weeks after childbirth. The procedure used up to 7 days after childbirth is slightly different.)

The Minilaparotomy Procedure

1. The provider uses proper infection-prevention procedures at all times (see Infection Prevention in the Clinic).

2. The provider performs a physical examination and a pelvic examination. The pelvic examination is to assess the condition and mobility of the uterus.

3. The woman usually receives light sedation (with pills or into a vein) to relax her. She stays awake. Local anesthetic is injected above the pubic hair line.

4. The provider makes a small vertical incision (2–5 centimeters) in the anesthetized area. This usually causes little pain. (For women who have just given birth, the incision is made horizontally at the lower edge of the navel.)

5. The provider inserts a special instrument (uterine elevator) into the vagina, through the cervix, and into the uterus to raise each of the 2 fallopian tubes so they are closer to the incision. This may cause discomfort.

6. Each tube is tied and cut or else closed with a clip or ring.

7. The provider closes the incision with stitches and covers it with an adhesive bandage.

8. The woman receives instructions on what to do after she leaves the clinic or hospital (see Explaining Self-Care for Female Sterilization, below). She can usually leave in a few hours. 

The Laparoscopy Procedure

1. The provider uses proper infection-prevention procedures at all times (see Infection Prevention in the Clinic).

2. The provider performs a physical examination and a pelvic examination. The pelvic examination is to assess condition and mobility of the uterus.

3. The woman usually receives light sedation (with pills or into a vein) to relax her. She stays awake. Local anesthetic is injected under her navel.

4. The provider places a special needle into the woman’s abdomen and, through the needle, inflates (insufflates) the abdomen with gas or air. This raises the wall of the abdomen away from the pelvic organs.

5. The provider makes a small incision (about one centimeter) in the anesthetized area and inserts a laparoscope. A laparoscope is a long, thin tube containing lenses. Through the lenses the provider can see inside the body and find the 2 fallopian tubes.

6. The provider inserts an instrument through the laparoscope (or, sometimes, through a second incision) to close off the fallopian tubes.

7. Each tube is closed with a clip or a ring, or by electric current applied to block the tube (electrocoagulation).

8. The provider then removes the instrument and laparoscope. The gas or air is let out of the woman’s abdomen. The provider closes the incision with stitches and covers it with an adhesive bandage.

9. The woman receives instructions on what to do after she leaves the clinic or hospital (see Explaining Self-Care for Female Sterilization, below). She can usually leave in a few hours.

Local Anesthesia Is Best for Female Sterilization

Local anesthesia, used with or without mild sedation, is preferable to general anesthesia. Local anesthesia: 

• Is safer than general, spinal, or epidural anesthesia
• Lets the woman leave the clinic or hospital sooner
• Allows faster recovery
• Makes it possible to perform female sterilization in more facilities

Sterilization under local anesthesia can be done when a member of the surgical team has been trained to provide sedation and the surgeon has been trained to provide local anesthesia. The surgical team should be trained to manage emergencies, and the facility should have the basic equipment and drugs to manage any emergencies.

Health care providers can explain to a woman ahead of time that being awake during the procedure is safer for her. During the procedure providers can talk with the woman and help to reassure her if needed.

Many different anesthetics and sedatives may be used. Dosage of anesthetic must be adjusted to body weight. Oversedation should be avoided because it can reduce the client’s ability to stay conscious and could slow or stop her breathing.

In some cases, general anesthesia may be needed. See Medical Eligibility Criteria for Female Sterilization, p. 168, for medical conditions needing special arrangements, which may include general anesthesia.

Supporting the user

Explaining Self-Care for Female Sterilization

Before the procedure the woman should

• Use another contraceptive until the procedure.
• Not eat anything for 8 hours before surgery. She can drink clear liquids until 2 hours before surgery.
• Not take any medication for 24 hours before the surgery (unless she is told to do so).
• Wear clean, loose-fitting clothing to the health facility if possible.
• Not wear nail polish or jewelry.
• If possible, bring a friend or relative to help her go home afterwards.

After the procedure the woman should

• Rest for 2 days and avoid vigorous work and heavy lifting for a week.
• Keep incision clean and dry for 1 to 2 days.
• Avoid rubbing the incision for 1 week.
• Not have sex for at least 1 week. If pain lasts more than 1 week, avoid sex until all pain is gone.

What to do about the most common problems

She may have some abdominal pain and swelling after the procedure. It usually goes away within a few days. Suggest ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever. She should not take aspirin, which slows blood clotting. Stronger pain reliever is rarely needed. If she had laparascopy, she may have shoulder pain or feel bloated for a few days.

Plan the follow-up visit

• Following up within 7 days or at least within 2 weeks is strongly recommended. No woman should be denied sterilization, however, because follow-up would be difficult or not possible.
• A health care provider checks the site of the incision, looks for any signs of infection, and removes any stitches. This can be done in the clinic, in the client’s home (by a specifically trained paramedical worker, for example), or at any other health center.

“Come Back Any Time”: Reasons to Return

Assure every client that she is welcome to come back any time—for example, if she has problems or questions, or she thinks she might be pregnant. (A few sterilizations fail and the woman becomes pregnant.)

Also if:

• She has bleeding, pain, pus, heat, swelling, or redness of the wound that becomes worse or does not go away
• She develops high fever (greater than 38° C/101° F)
• She experiences fainting, persistent light-headedness, or extreme dizziness in the first 4 weeks and especially in the first week

General health advice: anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the nurse or doctor what method she is using.