Abstract: We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3627 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review. One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare. Minor morbidity was higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence). Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence). When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence). When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence). We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods. Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures appear to be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Plain-language summary: We included 19 RCTs involving 13,209 women of childbearing age. The trials compared: - tubal rings versus clips (six RCTs, 4232 women); - partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); - tubal rings versus electrocoagulation (two RCTs, 599 women); - partial salpingectomy versus clips (four RCTs, 3827 women); - clips versus electrocoagulation (two RCTs, 206 women); and - two types of clips, i.e. Hulka clips versus Filshie clips (two RCTs, 2326 women). We found no RCTs that investigated sterilisation by chemicals or tubal inserts, so all the included studies involved an abdominal operation. There were no deaths reported with any method, and major and minor morbidity were rare. Pregnancy rates were less than 5/1000 procedures one year after surgery. Complicationrates (problems after surgery/minor morbidity) were very low for all methods compared. Minor complications, including pain, and technical failures were more common with rings than clips. Major morbidity and postoperative pain were more common with partial salpingectomy than with electrocoagulation. Postoperative pain was reported twice as often by women sterilised by tubal rings than those sterilised by electrocoagulation.Technical failures were more common with clips than cutting and tying techniques, but operating time was shorter for clips. We found little evidence concerning women's or surgeon's satisfaction. Tubal sterilisation by cutting and tying the tubes, or using electric current, clips or rings, is an effective method of contraception with few problems. The choice of method will depend upon the surgeon's experience, availability of equipment, setting, and cost. More research is needed about methods for tubal sterilisation that do not require an abdominal operation.