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To compare rates of gynecologic morbidity after laparoscopic and hysteroscopic sterilization.This retrospective cohort study used a commercial claims administrative database, 2007–2013, to compare rates of pregnancy, menstrual dysfunction, pelvic pain, hysteroscopic surgery, and intra-abdominal gynecologic surgery after laparoscopic and hysteroscopic sterilization. Women with 12 or more continuous months of data before and after their index procedure were included. Pregnancy rates after laparoscopic and hysteroscopic sterilization were compared for the entire population of women who underwent hysteroscopic sterilization and the subset who had completed postprocedure hysterosalpingograms. Cox proportional hazard models were calculated controlling for age, comorbidities, U.S. geographic region, metropolitan statistical area designation, and insurance type.A total of 42,391 women underwent laparoscopic and 27,724 underwent hysteroscopic sterilization. The pregnancy rate was higher after hysteroscopic than laparoscopic sterilization (adjusted hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.09–1.33; 2.4% compared with 2.0% risk of pregnancy at 2 years). Only 66.1% (n=18,318) of women who underwent hysteroscopic sterilization received a hysterosalpingogram. This group had similar pregnancy rates as those who underwent laparoscopic sterilization (adjusted HR 0.90, 95% CI 0.80–1.02; 1.8% compared with 2.0% at 2 years). After undergoing hysteroscopic sterilization, more women were diagnosed with menstrual dysfunction (adjusted HR 1.23, 95% CI 1.20–1.27; 26.8% compared with 22.3% at 2 years), and more women underwent hysteroscopic surgeries (adjusted HR 2.05, 95% CI 1.96–2.14; 13.8% compared with 6.4% at 2 years), but fewer women were diagnosed with pelvic pain (adjusted HR 0.83, P<.001; 21.0% compared with 25.6% at 2 years) and fewer women underwent intra-abdominal gynecologic surgeries (adjusted HR 0.95, 95% CI 0.90–0.99; 7.7% compared with 8.1% at 2 years), including hysterectomy (adjusted HR 0.65, 95% CI 0.61–0.69; 10.9% compared with 14.3% at 5 years).Hysteroscopic sterilization may be associated with a higher rate of pregnancy, more menstrual dysfunction, more hysteroscopic surgeries, less pelvic pain, and fewer intra-abdominal gynecologic surgeries than laparoscopic sterilization. Pregnancy rates appear to be similar for women who completed their postprocedure hysterosalpingogram, but only 66% of women did so.