Name ________________________________________ Chart No. _________________
I choose intrauterine contraception as my method of birth control and give permission to have it inserted. Two types of intrauterine contraceptives are available in the United States: a nonhormonal intrauterine device that uses copper as the contraceptive and a hormonal intrauterine system that releases levonorgestrel. Intrauterine contraception is over 99% effective when used correctly. The copper-containing IUD can be used for emergency contraception if inserted within 5 days of unprotected intercourse. I authorize (clinician’s name)_____________and/or contacted clinician or associate with (clinic) ______________ to perform the following procedure(s): _____________IUC removal and/or IUC insertion ___________________________________ and other related or incidental therapeutic procedure(s) that, in the judgment of the clinician referred to above, may be advisable.
BENEFITS:
The nature and benefits, expectations, major adverse events, risks and possible effects of the proposed procedure(s) have been explained to me, and I have been advised of the alternatives, my right to refuse such procedure(s) and the possible consequences of such a decision. I have read and understand the patient education handouts that have been provided.
- Rapid return to fertility
- Decreased risk of tubal pregnancy
- Reduction in cramps and menstrual blood flow (hormonal IUC)
- Possible protection against endometrial cancer
- Option if cannot use hormones (copper containing IUD)
RISKS/SIDE EFFECTS:
- Spotting, bleeding, Hemorrhage or anemia
- Partial or complete expulsion of device leading to pregnancy
- Puncturing of the uterus, embedding or cervical perforation
- Cramping or pelvic pain
- Lost string or other string problems
- Acne, headache, mood changes (hormonal IUC)
I need to call a doctor or the family planning clinic if I have any of the following early warning signs:
P Period late (pregnancy), abnormal spotting or bleeding
A Abdominal pain, pain with intercourse
I Infection exposure [any Sexually Transmitted Disease (STD)], abnormal discharge
N Not feeling well, fever, chills
S String missing, shorter or longer
ALTERNATIVES: I understand and have received verbal information about the other birth control methods, and I chose the IUC. For situations of suspected contraception failure, emergency contraception is available and offers a second chance to reduce the risk of unintended pregnancy. I have had sufficient opportunity to discuss the proposed procedure(s) with the clinician(s) referred to above, and my questions have been answered satisfactorily. I understand that any tissues or medical devices removed during this procedure will be disposed of by clinic staff in biohazard waste unless otherwise noted here:
INSTRUCTIONS: I have received information about how the IUC works and how it is inserted.
I understand the IUC does not protect against sexually transmitted infections.
I also understand that at any time, the clinician(s) may desire a second opinion regarding the necessity of any procedure(s) we are considering. The second opinion could be obtained by someone the clinician recommends or from someone I choose.
DECISION TO DISCONTINUE USE:
I am aware that the procedure may not accomplish the desired objectives and that no warranty or guarantee has been made as to the procedure(s), efficacy, result or cure. I understand that I may cease or discontinue the procedure(s) at any time, and for any reason, without fear of consequence or reprimand. I may have the IUC removed at any time.
QUESTIONS: I was allowed to ask questions about the IUC and may contact the clinic with further questions.
Client Signature _________________________________ Date _________________
Witness _______________________________________ Date _________________
INSTRUCTIONS FOR IUC USERS
INSERTION: An IUC may be inserted any time during the menstrual cycle if you are not pregnant. Before insertion, your clinician will perform a pelvic examination to determine the size, shape and position of the uterus. An instrument called a speculum will hold your vagina open, so the cervix can be seen.
The cervix is cleaned with an antiseptic solution. An instrument used to hold the uterus steady is attached. Another instrument is used to measure the depth and position of the uterus. The IUC is then inserted into the uterus.
Your provider may recommend medication before the IUC insertion to soften the cervix or help reduce cramping. The strings attached to the IUC will extend into the vagina.
You may be advised to remain lying down for a while following insertion and to rise slowly to prevent fainting.
CHECKING YOUR STRINGS: You can expel or lose the IUC without knowing it. You may not be protected against unplanned pregnancy if you cannot feel your strings or if you can feel part of the plastic. Check sanitary napkins and tampons for the IUC and feel for your strings routinely.
How to check for strings:
- Wash your hands with soap and water.
- Squat down or seat yourself on the toilet.
- Insert your middle finger deep into the vagina and locate the opening of the cervix (a round hole or slit-like opening in the center of the cervix). It feels firm, like the tip of your nose.
- Check that the strings are protruding through the cervix using caution not to pull on the strings.
- If you cannot feel the strings, can feel the plastic, or think the strings are longer than when you last checked, return to the clinic.
- Use a second method of birth control (such as spermicide and condoms) until you have been examined.
You may be instructed to return to the clinic within 1-3 months after placement of the IUC.
If you miss a period or think you are pregnant, return to the family planning clinic or your healthcare provider immediately.
You will be given a pamphlet about your IUC. The manufacturer produces the pamphlet. Read the entire pamphlet carefully.
You need to learn the side effects of the IUC and the early IUC danger signs (listed on the reverse side). Do not ignore a problem or wait to see if it will disappear. Call the Family Planning clinic or healthcare provider immediately to explain your problem. Note that the first letters of the early danger signs spell out the word PAINS.
IUC REPLACEMENT: The hormonal IUC must be replaced in 5-8 years, depending on the insertion type. The copper-containing IUD has been approved for 10 years of protection.
IUC REMOVAL: When you want to have your IUC removed, return to the clinic or your provider. Never try to remove the IUC yourself or have your partner pull on the strings.
Your provider will give you an informational card that tells you the type of IUC you have, the length of the strings, and when the IUC is due to be removed and/or replaced. Please keep this card for future reference.