Objective: To compare the probability of pregnancy after hysteroscopic compared to laparoscopic sterilization procedures. Methods: An evidence-based clinical decision analysis using a Markov model was performed to estimate the probability of pregnancy after a hysteroscopic sterilization procedure, a laparoscopic sterilization procedure with bipolar coagulation, and a laparoscopic sterilization procedure with silicone rubber band application over 10 years. For the model, procedure success, probability of completing follow-up testing, and risk of pregnancy after different sterilization procedures were estimated from published sources. Results: In the base case analysis, for all age groups, at all points in time after the sterilization procedure, the initial and cumulative risk of pregnancy after sterilization is higher for hysteroscopic than laparoscopic sterilization, either by bipolar coagulation or silicone band application. The pregnancy rate per 1,000 women at one year post-procedure is 56 women for hysteroscopic sterilization, 7 women for laparoscopic sterilization with silicone rubber band application, and 3 women for laparoscopic sterilization with bipolar coagulation. At ten years post-procedure, the cumulative pregnancy rate per 1,000 women is 84 women for hysteroscopic sterilization, 30 women for laparoscopic sterilization with silicone rubber band application, and 24 women for laparoscopic sterilization with bipolar coagulation. Sensitivity analyses predict that hysteroscopic and laparoscopic sterilization procedures would have an equivalent pregnancy risk of approximately 70 per 1,000 women at ten years if the probability of successful laparoscopic sterilization drops to 92% for both bipolar coagulation and silicone ring application, and the probability of successful bilateral coil placement on first hysteroscopic sterilization attempt increases to 97% or the probability of returning for a mandated HSG increases to 99%. Conclusion: Based on available data, the initial and cumulative risk of pregnancy after sterilization is higher for hysteroscopic than laparoscopic sterilization, either by bipolar coagulation or silicone band application.