FEMALE SURGICAL STERILIZATION
Sterilization does not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, the correct and consistent use of condoms is recommended. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.
CONDITION
* additional comments after this table
CATEGORYa
A = accept, C = caution,
D = delay, S = special
CLARIFICATIONS/EVIDENCE
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY
PREGNANCYD
YOUNG AGECClarification: Young women, like all women, should be counselled about the permanency of sterilization and the availability of alternative, long-term, highly effective methods.

Evidence: Studies show that up to 20% of women sterilized at a young age later regret this decision, and that young age is one of the strongest predictors of regret (including request for referral information and obtaining reversal) that can be identified before sterilization (119).
PARITY*
a) NulliparousA
b) ParousA
BREASTFEEDINGA
POSTPARTUM*
a) < 7 daysA
7 to < 42 daysD
≥ 42 daysA
b) Pre-eclampsia/eclampsia
 i) mild pre-eclampsiaA
 ii) severe pre-eclampsia/eclampsiaD
c) Prolonged rupture of membranes, 24 hours or moreD
d) Puerperal sepsis, intrapartum or puerperal feverD
e) Severe antepartum or postpartum haemorrhageD
f) Severe trauma to the genital tract (cervical or vaginal tear at time of delivery)D
g) Uterine rupture or perforationSClarification: If exploratory surgery or laparoscopy is conducted and the patient is stable, repair of the problem and tubal sterilization may be performed concurrently if no additional risk is involved.
POST-ABORTION*
a) UncomplicatedA
b) Post-abortal sepsis or feverD
c) Severe post-abortal haemorrhageD
d) Severe trauma to the genital tract (cervical or vaginal tear at time of abortion)D
e) Uterine perforationSClarification: If exploratory surgery or laparoscopy is conducted and the patient is stable, repair of the problem and tubal sterilization may be performed concurrently if no additional risk is involved.
f) Acute haematometraD
PAST ECTOPIC PREGNANCYA
SMOKING
a) Age < 35 yearsA
b) Age ≥ 35 years
i) < 15 cigarettes/dayA
ii) ≥ 15 cigarettes/dayA
OBESITYClarification: The procedure may be more difficult. There is an increased risk of wound infection and disruption. Obese women may have limited respiratory function and may be more likely to require general anaesthesia.

Evidence: Obese women were more likely to have complications when undergoing sterilization (2023).
a) ≥ 30 kg/m2 BMIC
b) Menarche to < 18 years and ≥ 30 kg/m2 BMIC
CARDIOVASCULAR DISEASE
MULTIPLE RISK FACTORS FOR ARTERIAL CARDIOVASCULAR DISEASE*
(such as older age, smoking, diabetes, hypertension and known dyslipidaemias)
S
HYPERTENSION

For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, the risk of cardiovascular disease may increase substantially. A single reading of blood pressure level is not sufficient to classify a woman as hypertensive.
a) Hypertension: adequately controlledC
b) Elevated blood pressure levels (properly taken measurements)Clarification: Elevated blood pressure should be controlled before surgery. There are increased anaesthesia-related risks and an increased risk of cardiac arrhythmia with uncontrolled hypertension. Careful monitoring of blood pressure intraoperatively is particularly necessary in this situation.
 i) systolic 140–159 or diastolic 90–99 mm HgC
 ii) systolic ≥ 160 or diastolic ≥ 100 mm HgS
c) Vascular diseaseS
HISTORY OF HIGH BLOOD PRESSURE DURING PREGNANCY
(where current blood pressure is measurable and normal)
A
DEEP VENOUS THROMBOSIS (DVT)/PULMONARY EMBOLISM (PE)Clarification: To reduce the risk of DVT/PE, early ambulation is recommended.
a) History of DVT/PEA
b) Acute DVT/PED
c) DVT/PE and established on anticoagulant therapyS
d) Family history (first-degree relatives)A
e) Major surgery
 i) with prolonged immobilizationD
 ii) without prolonged immobilizationA
f) Minor surgery without immobilizationA
KNOWN THROMBOGENIC MUTATIONS
(e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)
AClarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.
SUPERFICIAL VENOUS DISORDERS
a) Varicose veinsA
b) Superficial venous thrombosisA
CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE*
a) Current ischaemic heart diseaseD
b) History of ischaemic heart diseaseC
STROKE
(history of cerebrovascular accident)
C
KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORSAClarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening.
VALVULAR HEART DISEASE
a) UncomplicatedCClarification: The woman requires prophylactic antibiotics.
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)SClarification: The woman is at high risk for complications associated with anaesthesia and surgery. If the woman has atrial fibrillation that has not been successfully managed or current subacute bacterial endocarditis, the procedure should be delayed.
RHEUMATIC DISEASES
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

People with SLE are at increased risk of ischaemic heart disease, stroke and venous thromboembolism. Categories assigned to such conditions in the MEC should be the same for women with SLE who present with these conditions. For all categories of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors. Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives (2442).
a) Positive (or unknown) antiphospholipid antibodiesS
b) Severe thrombocytopeniaS
c) Immunosuppressive treatmentS
d) None of the aboveC
NEUROLOGIC CONDITIONS
HEADACHES
a) Non-migrainous (mild or severe)A
b) Migraine
 i) without aura
  age < 35 yearsA
  age ≥ 35 yearsA
 ii) with aura, at any ageA
EPILEPSYC
DEPRESSIVE DISORDERS
DEPRESSIVE DISORDERSC
REPRODUCTIVE TRACT INFECTIONS AND DISORDERS
VAGINAL BLEEDING PATTERNS
a) Irregular pattern without heavy bleedingA
b) Heavy or prolonged bleeding (includes regular and irregular patterns)A
UNEXPLAINED VAGINAL BLEEDING (suspicious for serious condition)Clarification: The condition must be evaluated before the procedure is performed.
a) Before evaluationD
ENDOMETRIOSISS
BENIGN OVARIAN TUMOURS
(including cysts)
A
SEVERE DYSMENORRHOEAA
GESTATIONAL TROPHOBLASTIC DISEASE
a) Decreasing or undetectable β-hCG levelsA
b) Persistently elevated β-hCG levels or malignant diseaseD
CERVICAL ECTROPIONA
CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)A
CERVICAL CANCER*
(awaiting treatment)
D
BREAST DISEASE
a) Undiagnosed massA
b) Benign breast diseaseA
c) Family history of cancerA
d) Breast cancer
 i) currentC
 ii) past and no evidence of current disease for 5 yearsA
ENDOMETRIAL CANCER*D
OVARIAN CANCER*D
UTERINE FIBROIDS*
a) Without distortion of the uterine cavityC
b) With distortion of the uterine cavityC
PELVIC INFLAMMATORY DISEASE (PID)*
a) Past PID (assuming no current risk factors for STIs)Clarification: A careful pelvic examination must be performed to rule out recurrent or persistent infection and to determine the mobility of the uterus.
 i) with subsequent pregnancyA
 ii) without subsequent pregnancyC
b) PID – currentD
STIS*
a) Current purulent cervicitis or chlamydial infection or gonorrhoeaDClarification: If no symptoms persist following treatment, sterilization may be performed.
b) Other STIs (excluding HIV and hepatitis)A
c) Vaginitis (including Trichomonas vaginalis and bacterial vaginosis)A
d) Increased risk of STIsA
HIV/AIDS
HIGH RISK OF HIVAClarification: No routine screening is needed. Appropriate infection prevention procedures, including universal precautions, must be carefully observed with all surgical procedures. The use of condoms is recommended following sterilization.
ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE
(WHO STAGE 1 OR 2)
AClarification: No routine screening is needed. Appropriate infection prevention procedures, including universal precautions, must be carefully observed with all surgical procedures. The use of condoms is recommended following sterilization.
SEVERE OR ADVANCED HIV CLINICAL DISEASE
(WHO STAGE 3 OR 4)
SClarification: The presence of an AIDS-related illness may require that the procedure be delayed.
OTHER INFECTIONS
SCHISTOSOMIASIS
a) UncomplicatedA
b) Fibrosis of the liver (if severe, see cirrhosis)CClarification: Liver function may need to be evaluated.
TUBERCULOSIS
a) Non-pelvicA
b) PelvicS
MALARIAA
ENDOCRINE CONDITIONS
DIABETES*Clarification: If blood glucose is not well controlled, referral to a higher-level facility is recommended.
a) History of gestational diseaseA
b) Non-vascular diseaseClarification: There is a possible decrease in healing and an increased risk of wound infection. Use of prophylactic antibiotics is recommended.
 i) non-insulin-dependentC
 ii) insulin-dependentC
c) Nephropathy/retinopathy/neuropathySEvidence: Diabetic women were more likely to have complications when undergoing sterilization (20).
d) Other vascular disease or diabetes of > 20 years' durationS
THYROID DISORDERS*
a) Simple goitreA
b) HyperthyroidS
c) HypothyroidC
GASTROINTESTINAL CONDITIONS
GALL BLADDER DISEASE
a) Symptomatic
 i) treated by cholecystectomyA
 ii) medically treatedA
 iii) currentD
b) AsymptomaticA
HISTORY OF CHOLESTASIS
a) Pregnancy relatedA
b) Past-COC relatedA
VIRAL HEPATITIS*Clarification: Appropriate infection-prevention procedures, including universal precautions, must be carefully observed with all surgical procedures.
a) Acute or flareD
b) CarrierA
c) ChronicA
CIRRHOSISClarification: Liver function and clotting might be altered. Liver function should be evaluated.
a) Mild (compensated)A
b) Severe (decompensated)S
LIVER TUMOURSClarification: Liver function and clotting might be altered. Liver function should be evaluated.
a) Benign
 i) focal nodular hyperplasiaA
 ii) hepatocellular adenomaC
b) Malignant (hepatoma)C
ANAEMIAS
THALASSAEMIAC
SICKLE CELL DISEASE*C
IRON-DEFICIENCY ANAEMIAClarification: The underlying disease should be identified. Both preoperative haemoglobin (Hb) level and operative blood loss are important factors in women with anaemia. If peripheral perfusion is inadequate, this may decrease wound healing.
a) Hb < 7 g/dlD
a) Hb ≥ 7 to < 10 g/dlC
OTHER CONDITIONS RELEVANT ONLY FOR FEMALE SURGICAL STERILIZATION
LOCAL INFECTIONDClarification: There is an increased risk of postoperative infection.
COAGULATION DISORDERS*S
RESPIRATORY DISEASES
a) Acute (bronchitis, pneumonia)DClarification: The procedure should be delayed until the condition is corrected. There are increases in anaesthesia-related and other perioperative risks.
b) Chronic
 i) asthmaS
 ii) bronchitisS
 iii) emphysemaS
 iv) lung infectionS
SYSTEMIC INFECTION OR GASTROENTERITIS*D
FIXED UTERUS DUE TO PREVIOUS SURGERY OR INFECTION*S
ABDOMINAL WALL OR UMBILICAL HERNIASClarification: Hernia repair and tubal sterilization should be performed concurrently if possible.
DIAPHRAGMATIC HERNIA*C
KIDNEY DISEASE*C
SEVERE NUTRITIONAL DEFICIENCIES*C
PREVIOUS ABDOMINAL OR PELVIC SURGERYCEvidence: Women with previous abdominal or pelvic surgery were more likely to have complications when undergoing sterilization (20, 22, 4345).
STERILIZATION CONCURRENT WITH ABDOMINAL SURGERY
a) ElectiveC
b) Emergency (without previous counselling)D
c) Infectious conditionD
STERILIZATION CONCURRENT WITH CAESAREAN SECTION*A
a

Further explanation of A, C, D and S categories:

  • A = accept: There is no medical reason to deny sterilization to a person with this condition.
  • C = caution: The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
  • D = delay: The procedure is delayed until the condition is evaluated and/or corrected. Alternative temporary methods of contraception should be provided.
  • S = special: The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anaesthesia, and other back-up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided if referral is required or there is otherwise any delay.

From: II, Using the recommendations

Cover of Medical Eligibility Criteria for Contraceptive Use
Medical Eligibility Criteria for Contraceptive Use. 5th edition.
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