Previous changes

May 2021 — reviewed. A literature search was conducted in April 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic.

• No changes to clinical recommendations have been made, but the topic structure has been changed. 
• The Quality and Outcomes Framework (QOF) indicators listed below have been removed as they were retired in April 2019 [BMS and NHS England, 2019]:
  • CON001: The contractor establishes and maintains a register of women aged 54 or under who have been prescribed any method of contraception at least once in the last year, or other clinically appropriate interval, for example, the last 5 years for an IUS.
  • CON003: The percentage of women, on the register, prescribed emergency hormonal contraception one or more times in the preceding 12 months by the contractor who have received information from the contractor about long-acting reversible contraception at the time or within one month of the prescription.

April to June 2016 — reviewed. A literature search was conducted in April 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. Minor structural changes have been made to this topic.

June 2013 — minor update. The 2013 Quality and Outcomes Framework (QOF) options for local implementation have been added to this topic.

March 2013 — minor update. The telephone number for NHS Direct has been updated.

February to June 2012 — reviewed. A literature search was conducted in December 2011 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made. However, recommendations have been rewritten for clarity, and superseded guidelines and manufacturers' Summary of Product Characteristics have been updated accordingly.

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

February 2010 — updated to include the revised UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) published by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC). Issued in January 2010.

March 2009 — minor update. The QOF indicators for sexual health (2009) have been updated in the Goals and outcome measures section.

April to September 2007 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

July 2006 — minor update. Information regarding orlistat and reduced efficacy of oral contraceptives has been included in the section on Drug interactions. 

January 2006 — minor update. Gynol II Jelly, Microval tablets, and Duragel have been discontinued, and the prescriptions have been removed. Black triangle status has been removed from Cerazette®. 

October 2005 — updated to include the new recommendations on missed pills from the FFPRHC Clinical Effectiveness Unit (2005). 

April 2005 — minor update. Neogest® tablets have been discontinued, and the prescriptions have been removed. Issued in April 2005.

February 2005 — updated to include prescribing advice from the Committee on Safety of Medicines (2005) on the effect of depot medroxyprogesterone acetate (DMPA) contraception on bones.

September 2004 — updated to include the World Health Organization (WHO) Medical Eligibilty Criteria relating to contraception for 2004 and recent licence changes to Cerazette®. Delfen® contraceptive foam is being discontinued at the end of October 2004, and the prescriptions have been removed. Issued in September 2004.

January 2004 — reviewed. Validated in March 2004 and issued in June 2004.

January 2001 — rewritten. Validated in March 2001 and issued in June 2001. Guidance on emergency contraception is no longer included in the Contraception guidance but can be found as a separate CKS topic.

December 1997 — written.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 May 2021.

HTAs (Health Technology Assessments)

No new HTAs since 1 May 2021.

Economic appraisals

No new economic appraisals relevant to England since 1 May 2021.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 May 2021.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 May 2021.

New policies

No new national policies or guidelines since 1 May 2021.

New safety alerts

No new safety alerts since 1 May 2021.

Changes in product availability

No changes in product availability since 1 May 2021.

What are the advantages, disadvantages, and risks of male sterilization?

• Advantages
  • It is very effective at preventing pregnancy.
  • It is considered a permanent method of contraception.
• Disadvantages
  • It requires a minor surgical procedure.  
  • Effective contraception is required until azoospermia is confirmed (12 weeks is the optimal time to schedule a post-vasectomy semen analysis [PVSA]). 
  • People may regret having had the procedure.
    • The pre-sterilization assessment process is designed to ensure that people at risk for regret are identified and fully informed about alternative long-acting reversible contraceptive methods. 
  • It cannot easily be reversed, and the NHS does not routinely offer reversal procedures.
  • It does not protect against sexually transmitted infections (STIs).
• Risks
  • There is a small risk of haematoma and/or infection after the procedure.
  • There is a risk of chronic post-vasectomy pain (CPVP), a postoperative testicular, scrotal, penile, or lower abdominal pain that occurs more than 3 months after the procedure and is rarely severe and persistent in some men. The incidence rate of CPVP ranges from 1–14%.
  • Rarely, the procedure may fail and pregnancy can occur.
    • Late failure is defined as the presence of sperm after confirmation of sterility (azoospermia or special clearance at PVSA). 
  • Male sterilization has been associated with an increased risk of prostate cancer, but this link is unlikely to be causal.
  • Male sterilization does not increase the risk of impotence, testicular cancer, or heart disease.

[CoSRH, 2014; SOGC, 2015]

What are the advantages, disadvantages, and risks associated with female sterilization?

• Advantages 
  • It is very effective at preventing pregnancy.
  • It is considered a permanent method of contraception.
• Disadvantages
  • It requires a surgical procedure.
  • Effective contraception must be continued for a period of time following sterilization, depending on the method used. 
  • People may regret having had the procedure.
    
    • The pre-sterilization assessment process is designed to ensure that people at risk for regret are identified and fully informed about alternative long-acting reversible contraceptive methods. 
  • It cannot easily be reversed, and the NHS does not routinely offer reversal procedures.
  • It does not protect against sexually transmitted infections (STIs).
• Risks
  
  • The procedure can fail, but this is uncommon.
  • If the procedure fails, the resulting pregnancy may be ectopic.
    • The risk varies depending on the method used, but the 10-year cumulative probability of ectopic pregnancy ranges from 2.4–7.3 per 1000 procedures.
  • Laparoscopic sterilization is done under general anaesthesia, which is associated with several risks and complications.
  • Other complications associated with laparoscopic surgery include injuries to the bowel, bladder, or blood vessels requiring laparotomy or leading to death.
    • The risk of laparotomy as a consequence of a severe complication of laparoscopic surgery is about 2 per 1000 procedures.
    • The risk of death with laparoscopy is about 1 in 12,000 procedures.
  • Evidence suggests that there is an association between tubal occlusion and an increased risk of subsequent hysterectomy, but there is no evidence of causation.
  • Women may report worsening menstrual symptoms following tubal occlusion, but there is no evidence to suggest a causal effect. There is no evidence that tubal occlusion results in significant changes to hormone levels.
  • Female cancers:
    • Tubal occlusion is not associated with an increased risk of ovarian cancer. Evidence suggests that the procedure may have a protective effect against developing ovarian cancer that persists over time.
    • There is no available evidence of an association between tubal occlusion and breast cancer.
    • Available evidence suggests that there is no association between tubal occlusion and cervical or endometrial cancer risk.

[CoSRH, 2014]

How should l assess a man considering sterilization?

• If a man is considering sterilization:
  • An assessment should be done to confirm the suitability of the method. As part of the assessment, the World Health Organization Medical Eligibility Criteria for Contraceptive Use should be applied to assess his eligibility for use of the method.
  • His level of understanding of the procedure should be assessed, as well as his mental capacity to make the decision and the risk for later regret. 
  • His partner's suitability for sterilization should also be assessed, as the couple's clinical history, present symptoms, and/or examination findings may influence which partner goes forward to have sterilization. 
• See the CKS topic on Contraception - assessment for information on how to assess a man considering sterilization.

What information and advice should I give a man considering sterilization?

• Provide verbal and written information on male sterilization.
  • This should include information on:
    • The sterilization procedure.
    • How effective male sterilization is at preventing pregnancy, including the failure rate relative to other methods of contraception, such as long-acting reversible contraception (LARC).
    • The advantages and disadvantages of male sterilization. 
    • Alternative long-term reversible methods of contraception, including information on the advantages, disadvantages, and relative efficacy of each method. 
  • Information on male sterilization is available from several sources, including:
    • The NHS website (www.nhs.uk).
    • Sexwise, a website produced by the FPA (Family Planning Association) for the National Health Promotion Programme for Sexual Health and Reproductive Health (www.sexwise.org.uk).
• Provide information on male sterilization reversal and the success rate of reversal operations.
  • Advise that:
    • The NHS does not routinely offer reversal operations.
    • Reported success rates (the presence of motile sperm in a post-operative semen sample) of reversal operations vary from 40% to over 97%. 
    • The success rate reduces the longer the time interval from the vasectomy.
• After the procedure, provide follow-up and aftercare advice.

What follow-up and aftercare advice should I give a man who has had a vasectomy?

• Advise the man to: 
  • Seek medical help if he develops any health concerns following the procedure, such as: 
    • Persistent bleeding.
    • Pain.
    • Infection.
    • Rapidly enlarging one-sided scrotal haematoma. 
  • Take a nonsteroidal anti-inflammatory drug (NSAID) for pain or discomfort following the procedure, unless contraindicated. See the CKS topic on NSAIDs - prescribing issues for more information.
  • Rest and refrain from strenuous activity until pain permits.
  • Abstain from sexual activity for between 2–7 days after the procedure.
  • Wear supportive underpants or athletic support for the first few days following the procedure, including at night for the initial 48 hours, or longer according to symptoms. This is to support the scrotum and reduce discomfort.
• Remind the man of the need to use effective contraception until azoospermia has been confirmed by post-vasectomy semen analysis (PVSA).
  
  • Ensure that the man has been provided with instructions regarding PVSA and provided with sample bottles if PVSA postal samples are used.
  • The way in which azoospermia is confirmed depends on local protocols, but the optimal time to schedule a PVSA is 12 weeks after the procedure. 
  • In a small minority of men, non-motile sperm persist after vasectomy. In such cases, 'special clearance' to stop contraception may be given when fewer than 100,000 non-motile sperm/mL are found in a fresh specimen examined at least 7 months after vasectomy.

How should I assess a woman considering sterilization?

• If a woman is considering sterilization:
  • An assessment should be done to confirm the suitability of the method. As part of the assessment, the World Health Organization Medical Eligibility Criteria for Contraceptive Use should be applied to assess her eligibility for use of the method.
  • Her level of understanding of the procedure should be assessed, as well as her mental capacity to make the decision and the risk for later regret. 
  • Her partner's suitability for sterilization should also be assessed, as the couple's clinical history, present symptoms, and/or examination findings may influence which partner goes forward to have sterilization. 
• See the CKS topic on Contraception - assessment for information on how to assess a woman considering sterilization.

What information and advice should I give to a woman considering tubal occlusion?

• Provide verbal and written information on female sterilization.
  
  • This should include information on:
    • The sterilization procedure.
    • How effective female sterilization is at preventing pregnancy, including the failure rate relative to other methods of contraception, such as long-acting reversible contraception (LARC).
    • The advantages and disadvantages of female sterilization. 
    • Alternative long-term reversible methods of contraception, including information on the advantages, disadvantages, and relative efficacy of each method. 
  • Information on female sterilization is available from several sources, including:
    • The NHS website (www.nhs.uk).
    • Sexwise, a website produced by the FPA (Family Planning Association) for the National Health Promotion Programme for Sexual Health and Reproductive Health (www.sexwise.org.uk).
• Provide information on female sterilization reversal and the success rate of reversal operations.
  • Advise that:
    • The NHS does not routinely provide reversal operations.
    • The success of reversal procedures depends on a number of factors including the age of the woman, the method used for tubal occlusion, and the method used for tubal re-anastomosis.
    • Pregnancy rates following reversal range from 31–92%.  
• After the procedure, provide follow-up and aftercare advice.

What follow-up and aftercare advice should I give a woman who has undergone tubal occlusion?

• Advise the woman:
  • On appropriate self-care, including: 
    • Analgesia for pain or discomfort following the procedure. See the CKS topic on Analgesia - mild-to-moderate pain for more information.
    • Wound care information, if appropriate — she should keep the incision clean and dry for 1–2 days.
  • To avoid rigorous physical activity for 1 week after the procedure.
  • To avoid sex for at least 1 week after the procedure.
  • On when to seek medical help, including if she develops the following: 
    • Abdominal pain, especially if accompanied by temperature, loss of appetite, vomiting, and generally feeling unwell — may indicate a bowel perforation.
    • Abdominal pain associated with missed periods — may indicate an ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
    • A painful, red, swollen, warm calf, or difficult weight-bearing on the leg — may indicate deep vein thrombosis. See the CKS topic on Deep vein thrombosis for more information.
    • Burning and stinging when passing urine, or urinating frequently — may indicate a urinary tract infection. See the CKS topic on Urinary tract infection (lower) - women for more information.
    • Red and painful skin around the scars — may indicate skin infection. See the CKS topic on Cellulitis - acute for more information.
• Following laparoscopic sterilization:
  • Advise women using combined hormonal contraception (CHC), the progestogen-only pill (POP), or non-hormonal contraception to continue their contraceptive method for at least 7 days after the procedure.
  • If the procedure is scheduled for the hormone-free interval or day 1 of a cycle of CHC, the hormone-free interval should be omitted or CHC should be restarted, and CHC should be continued for at least 7 days after the procedure.
• Following hysteroscopic sterilization:
  • Advise that additional contraception (such as condoms) will need to be used until successful placement of the micro-inserts and tubal occlusion is confirmed (by X-ray, ultrasound scan, or hysterosalpingogram) at least 3 months after the procedure.