Study Objectives: To examine the surgical indications and pathologic findings in patients undergoing a second surgery after placement of the Essure permanent birth control system to determine the role of Essure in developing new-onset pelvic pain. Design: Retrospective cohort (Canadian Task Force classification II-2). Setting: Tertiary-level hospital. Patients: Women who have had Essure placement and subsequent second surgery. Intervention: Charts from women undergoing pelvic surgery after Essure placement from June 2002 to June 2013 were reviewed and the indication for the procedure, surgical and pathologic findings noted. Measurements and Main Results: Of 1430 patients, 62 (4.3%) had a second surgery after Essure placement, and 24 of these (1.6%) had a surgical indication not related to pain. The remaining 38 patients (2.7%) had either new-onset (n = 27) or worsening pre-existing pain (n = 11). In the new-onset pain group, 15 (1%) had surgical findings or pathology consistent with a painful gynecologic condition. In the remaining 12, 8 (0.5%) seemed to be related to some perforation or migration of the Essure device. In 4 patients (0.3%) with no other obvious cause for the new-onset pain, it was thus attributed to the Essure microinsert. Conclusion: Essure sterilization can be associated with new-onset pain or a worsening of a pre-existing painful gynecologic condition, although both are very rare. A careful and complete consent before placement and a thorough examination if pain does occur usually show some etiology for the pain other than the Essure insert. (C) 2016 AAGL. All rights reserved.