[Table, Surgical sterilization procedures (STER)]. - Medical Eligibility Criteria for Contraceptive Use

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	CATEGORY^a A = accept, C = caution, D = delay, S = special	CLARIFICATIONS/EVIDENCE
PERSONAL CHARACTERISTICS AND REPRODUCTIVE HISTORY

PREGNANCY	D

YOUNG AGE	C	Clarification: 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 (1–19).

PARITY*
a) Nulliparous	A
b) Parous	A

BREASTFEEDING	A

POSTPARTUM*
a) < 7 days	A
7 to < 42 days	D
≥ 42 days	A
b) Pre-eclampsia/eclampsia
i) mild pre-eclampsia	A
ii) severe pre-eclampsia/eclampsia	D
c) Prolonged rupture of membranes, 24 hours or more	D
d) Puerperal sepsis, intrapartum or puerperal fever	D
e) Severe antepartum or postpartum haemorrhage	D
f) Severe trauma to the genital tract (cervical or vaginal tear at time of delivery)	D
g) Uterine rupture or perforation	S	Clarification: 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) Uncomplicated	A
b) Post-abortal sepsis or fever	D
c) Severe post-abortal haemorrhage	D
d) Severe trauma to the genital tract (cervical or vaginal tear at time of abortion)	D
e) Uterine perforation	S	Clarification: 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 haematometra	D

PAST ECTOPIC PREGNANCY	A

SMOKING
a) Age < 35 years	A
b) Age ≥ 35 years
i) < 15 cigarettes/day	A
ii) ≥ 15 cigarettes/day	A

OBESITY		Clarification: 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 (20–23).
a) ≥ 30 kg/m² BMI	C
b) Menarche to < 18 years and ≥ 30 kg/m² BMI	C

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 controlled	C
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 Hg	C
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg	S
c) Vascular disease	S

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/PE	A
b) Acute DVT/PE	D
c) DVT/PE and established on anticoagulant therapy	S
d) Family history (first-degree relatives)	A
e) Major surgery
i) with prolonged immobilization	D
ii) without prolonged immobilization	A
f) Minor surgery without immobilization	A

KNOWN THROMBOGENIC MUTATIONS (e.g. factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)	A	Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening.

SUPERFICIAL VENOUS DISORDERS
a) Varicose veins	A
b) Superficial venous thrombosis	A

CURRENT AND HISTORY OF ISCHAEMIC HEART DISEASE*
a) Current ischaemic heart disease	D
b) History of ischaemic heart disease	C

STROKE (history of cerebrovascular accident)	C

KNOWN DYSLIPIDAEMIAS WITHOUT OTHER KNOWN CARDIOVASCULAR RISK FACTORS	A	Clarification: Routine screening is not appropriate because of the rarity of the condition and the high cost of screening.

VALVULAR HEART DISEASE
a) Uncomplicated	C	Clarification: The woman requires prophylactic antibiotics.
b) Complicated (pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis)	S	Clarification: 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 (24–42).

a) Positive (or unknown) antiphospholipid antibodies	S
b) Severe thrombocytopenia	S
c) Immunosuppressive treatment	S
d) None of the above	C

NEUROLOGIC CONDITIONS

HEADACHES
a) Non-migrainous (mild or severe)	A
b) Migraine
i) without aura
age < 35 years	A
age ≥ 35 years	A
ii) with aura, at any age	A

EPILEPSY	C

DEPRESSIVE DISORDERS

DEPRESSIVE DISORDERS	C

REPRODUCTIVE TRACT INFECTIONS AND DISORDERS

VAGINAL BLEEDING PATTERNS
a) Irregular pattern without heavy bleeding	A
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 evaluation	D

ENDOMETRIOSIS	S

BENIGN OVARIAN TUMOURS (including cysts)	A

SEVERE DYSMENORRHOEA	A

GESTATIONAL TROPHOBLASTIC DISEASE
a) Decreasing or undetectable β-hCG levels	A
b) Persistently elevated β-hCG levels or malignant disease	D

CERVICAL ECTROPION	A

CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)	A

CERVICAL CANCER* (awaiting treatment)	D

BREAST DISEASE
a) Undiagnosed mass	A
b) Benign breast disease	A
c) Family history of cancer	A
d) Breast cancer
i) current	C
ii) past and no evidence of current disease for 5 years	A

ENDOMETRIAL CANCER*	D

OVARIAN CANCER*	D

UTERINE FIBROIDS*
a) Without distortion of the uterine cavity	C
b) With distortion of the uterine cavity	C

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 pregnancy	A
ii) without subsequent pregnancy	C
b) PID – current	D

STIS*
a) Current purulent cervicitis or chlamydial infection or gonorrhoea	D	Clarification: 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 STIs	A

HIV/AIDS

HIGH RISK OF HIV	A	Clarification: 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)	A	Clarification: 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)	S	Clarification: The presence of an AIDS-related illness may require that the procedure be delayed.

OTHER INFECTIONS

SCHISTOSOMIASIS
a) Uncomplicated	A
b) Fibrosis of the liver (if severe, see cirrhosis)	C	Clarification: Liver function may need to be evaluated.

TUBERCULOSIS
a) Non-pelvic	A
b) Pelvic	S

MALARIA	A

ENDOCRINE CONDITIONS

DIABETES*		Clarification: If blood glucose is not well controlled, referral to a higher-level facility is recommended.
a) History of gestational disease	A
b) Non-vascular disease		Clarification: There is a possible decrease in healing and an increased risk of wound infection. Use of prophylactic antibiotics is recommended.
i) non-insulin-dependent	C
ii) insulin-dependent	C
c) Nephropathy/retinopathy/neuropathy	S	Evidence: Diabetic women were more likely to have complications when undergoing sterilization (20).
d) Other vascular disease or diabetes of > 20 years' duration	S

THYROID DISORDERS*
a) Simple goitre	A
b) Hyperthyroid	S
c) Hypothyroid	C

GASTROINTESTINAL CONDITIONS

GALL BLADDER DISEASE
a) Symptomatic
i) treated by cholecystectomy	A
ii) medically treated	A
iii) current	D
b) Asymptomatic	A

HISTORY OF CHOLESTASIS
a) Pregnancy related	A
b) Past-COC related	A

VIRAL HEPATITIS*		Clarification: Appropriate infection-prevention procedures, including universal precautions, must be carefully observed with all surgical procedures.
a) Acute or flare	D
b) Carrier	A
c) Chronic	A

CIRRHOSIS		Clarification: Liver function and clotting might be altered. Liver function should be evaluated.
a) Mild (compensated)	A
b) Severe (decompensated)	S

LIVER TUMOURS		Clarification: Liver function and clotting might be altered. Liver function should be evaluated.
a) Benign
i) focal nodular hyperplasia	A
ii) hepatocellular adenoma	C
b) Malignant (hepatoma)	C

ANAEMIAS

THALASSAEMIA	C

SICKLE CELL DISEASE*	C

IRON-DEFICIENCY ANAEMIA		Clarification: 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/dl	D
a) Hb ≥ 7 to < 10 g/dl	C

OTHER CONDITIONS RELEVANT ONLY FOR FEMALE SURGICAL STERILIZATION

LOCAL INFECTION	D	Clarification: There is an increased risk of postoperative infection.

COAGULATION DISORDERS*	S

RESPIRATORY DISEASES
a) Acute (bronchitis, pneumonia)	D	Clarification: The procedure should be delayed until the condition is corrected. There are increases in anaesthesia-related and other perioperative risks.
b) Chronic
i) asthma	S
ii) bronchitis	S
iii) emphysema	S
iv) lung infection	S

SYSTEMIC INFECTION OR GASTROENTERITIS*	D

FIXED UTERUS DUE TO PREVIOUS SURGERY OR INFECTION*	S

ABDOMINAL WALL OR UMBILICAL HERNIA	S	Clarification: 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 SURGERY	C	Evidence: Women with previous abdominal or pelvic surgery were more likely to have complications when undergoing sterilization (20, 22, 43–45).

STERILIZATION CONCURRENT WITH ABDOMINAL SURGERY
a) Elective	C
b) Emergency (without previous counselling)	D
c) Infectious condition	D

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.

Geneva: World Health Organization; 2015.

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