Consent for Intrauterine Device Insertion at Medical Services

I am requesting removal / insertion of an Intrauterine Device or IUD (Mirena, Kyleena, Paragard). 

About the IUDs

Paragard IUD protects against pregnancy for 12 years. While using Paragard, my period may get heavier or last longer. 

Mirena IUD protects against pregnancy for 8 years. While using Mirena, my period may get lighter or disappear. I understand this is not dangerous.

Kyleena IUD protects against pregnancy for 5 years. While using Mirena, my period may get lighter or disappear. I understand this is not dangerous. 

I have been counseled about all other methods of birth control and understand how they compare to the IUD in terms of effectiveness, mode of action, advantages and disadvantages, risks and benefits, side effects and warning signs. 

I understand that IUDs do not protect against sexually transmitted infections (STIs). 

I understand that IUDs may be used as Emergency Contraception up to 5 days after unprotected sex. 

Prior to procedure

I understand that I must take a pregnancy test and show a negative result before an IUD is inserted. 

If I had unprotected sex in the past 7 days, the test may not be accurate and may read negative when early pregnancy is starting. 

I have been told that the following conditions preclude the use of an IUD: 

  • Pregnancy 
  • Pelvic Infection 
  • Current or recent gonorrhea or chlamydia infection
  • Copper Allergy 
  • Uterine anomalies 
  • Undiagnosed genital bleeding 
  • Cervical or reproductive cancer 

During procedure 

My sexual and medical histories have been reviewed. 

If inserting Paragard, I do not have any of the following conditions: 

  • Anemia 
  • Need for anticoagulant therapy 
  • Severe menstrual cramps or heavy menstrual flow 

I will be tested for STIs during my IUD visit. 

Possible complications, though unlikely, have been explained to me. These include but are not limited to: pelvic infection, perforation of the uterus, severe cramping, allergic reaction and bleeding. 

I have received patient information about side effects to expect after the IUD is inserted. While insertion is expected, I have been given no guarantee that this procedure will be successful. 

After procedure 

I can expect irregular or heavier bleeding and cramping for the first 3-6 months after insertion, as the body adjusts to the new IUD. 

Warning signs that I should see a provider for include: 

  • Severe pain and bleeding with sex 
  • Any symptoms of pregnancy 
  • Unusual cramping or soreness in the pelvic region 
  • Unusual vaginal discharge 
  • Unexplained fever, chills, or trouble breathing 

I may check the strings of the IUD to make sure it is in the right place. 

I understand that over time the threads may soften and tuck around the side of the cervix making feeling them with fingers more difficult. 

I understand that exams to check STIs are recommended on a regular basis. 

In the event of a problem, I am to call Medical Services 212-854-7426 to make an appointment with a provider.