IUD Insertion Consent Form

Patient Consent Form
For the Insertion of Mirena IUD

 Please read this form carefully before you have your consultation with the doctor.
 You should tick or mark the box next to each paragraph to indicate that you have read
and understood that section.
 You will have the opportunity to discuss any specific questions or concerns that you may
have when you talk with the doctor.
 Please do not sign this consent form until you have spoken with the doctor.
Name: _________________________________________________ DOB: _________________
Overview of treatment
 A Mirena IUD is a small T-shaped plastic device which will slowly release a progestogen
hormone inside the womb for 5 years. The Mirena device is inserted through the cervix, the
natural opening into the womb, and this procedure can be done with oral pain killer prior to
make the process much more comfortable. The Mirena IUD provides effective protection from
unplanned pregnancies for up to 5 years, but is also used to control heavy menstrual bleeding.
Alternative long-acting contraceptives

 Non-hormonal intrauterine devices (IUDs) which are made from copper and plastic, and which
have similar effectiveness to a Mirena IUD. Some copper-based IUDs can be used for longer
than 5 years. A copper-based IUD will sometimes cause heavier, longer and possibly more
painful menstrual periods.
 The Implanon hormonal implant, which is inserted under the skin of your upper arm and
which lasts for 3 years.
 Depo Provera Injection, the contraceptive injection called Depot Medroxyprogesterone Acetate
(DMPA), is similar to the hormone called progesterone, which is produced in the body by the
ovaries. In Australia, it is sold as Depo-Provera® and Depo-Ralovera®. Each injection of
DMPA provides protection against pregnancy for 12 weeks. The contraceptive injection mainly
works by stopping the ovaries from releasing an egg (ovulation).
Contraindications or precautions
 A Mirena IUD should not be inserted in the following circumstances - current or recurring
infection in your pelvis or uterus; a recent (within 3 months) sexually transmitted infection;
untreated bacterial vaginosis; undiagnosed abnormal vaginal bleeding; an abnormal Pap smear
which may require further treatment; abnormalities of the uterus cavity; acute liver disease;
known or suspected pregnancy; known or suspected carcinoma of the breast.
 The following conditions may increase the risk of problems with the use of a Mirena IUD-
previous deep vein thrombosis (DVT); uterine scars; uterine fibroids; migraines or severe
headaches; having multiple sexual partners. Women who have not had children or a vaginal
delivery of a child may sometimes find Mirena uncomfortable around the time of insertion.
Risks and side effects

 The insertion of a Mirena is associated with some short-term discomfort and cramping.
 There is usually some light to moderate vaginal bleeding after the insertion of a Mirena, and
that this bleeding generally settles over a few weeks, but may sometimes last for a few months.
 The bleeding with my periods will be greatly reduced when I am using a Mirena, and that my
periods may stop altogether.
 There is a risk of infection when an intrauterine contraceptive is used, and that this risk is
highest in the first month after insertion.
 An intrauterine contraceptive does not protect against sexually transmitted infections, and that
I should take appropriate precautions if I am at risk of a sexually transmitted infection.
 The Mirena device can sometimes fall out, and that I should get advice about what to do if
this does happen.
 Hormonal effects from Mirena are not common, but can include mood changes, headaches,
acne, breast tenderness and weight gain.
 A Mirena device provides very good contraception over 5 years, and that at the end of the 5
years I should have the device removed, and a new Mirena inserted, if I wish to continue using
this method of contraception.
 No method of contraception, including Mirena, is completely reliable, and that I must seek early
review to exclude an ectopic pregnancy if I fall pregnant with an intrauterine device in my
womb.
 There is a very small risk of having a hole put in the wall of the womb during the insertion
procedure.
 The string that comes through the cervix into the top part of the vagina may need to be
trimmed at a later date.
 Heavy smokers and very overweight or obese patients have an increased risk of surgical
complications.
Additional Unforseen Costs

 It is sometimes necessary to arrange for additional diagnostic tests or for treatment at another
facility by another medical practitioner, in circumstances that were not foreseeable or not
known to be needed at the time this consent was given. You will be advised if any such tests or
referrals are necessary, but you will be responsible for any costs that may arise if this happens.
I am aware that I must seek medical advice, either from The Private Clinic or my usual doctor, if any
of the following problems develop:
 fever or chills that develop within 3 weeks of the Mirena IUD insertion
 unexplained pain in the lower abdomen
 heavy vaginal bleeding
 possible infection or sexually transmitted infection exposure
 abnormal or concerning vaginal discharge
 the string from the Mirena feels longer than before or appears to be missing
Instructions for after the Mirena insertion

 I understand that I must see a doctor for an initial check on the Mirena IUD about 4 to 6
weeks after the insertion procedure
 I am aware that for the next three days after the insertion procedure today I should not have sex,
that I should use sanitary pads and not tampons for any vaginal bleeding, and that I should not
go swimming, sit in a bath or spa, but may have normal showers for personal hygeine.
Decision to discontinue use

 I understand that I may have the Mirena IUD removed at any time, but that, if I still do not wish
to become pregnant, then I must plan to use another method of contraception.
 If I wish to have the Mirena IUD removed, then I should seek the help of a suitably qualified
practitioner and not try to remove the device myself.
Do you have any specific concerns or questions?

……………………………….…………………………………………………………………………
……………………………….…………………………………………………………………………
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By signing this consent form

 I am requesting and consenting to the insertion of a Mirena IUD, along with other
medications normally associated with this procedure.
 I am acknowledging that I have read and understood this consent form. I have had the
opportunity to ask the doctor questions, and I am satisfied with the answers to these questions.
 I understand that it is my responsibility to make arrangements for the removal or replacement
of the Mirena IUD after 5 years of use.
 I acknowledge that no guarantees or assurances have been made to me concerning the results
of this procedure.
 I understand that it is impossible to list every possible adverse outcome or complication that
could occur, and that surgical procedures may not always be successful. I accept all risks,
whether stated or unstated, and I understand that complications can occur with any procedure.
Patient signature: __________________________________________ Date ____/____/____

(to be signed during the consultation with the doctor)
I have consulted with the patient, explained the procedure and answered any of her questions. I
believe that she has understood the nature and purpose of the procedure and wishes to proceed.
Doctor’s signature: __________________________________________
Doctor’s name: __________________________________________ ____/____/____

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IUD Insertion Consent Form

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Patient Consent Form

For the Insertion of Mirena IUD

Name: _________________________________ DOB: _

Alternative long-acting contraceptives

Risks and side effects

Additional Unforseen Costs

Instructions for after the Mirena insertion

Decision to discontinue use

Do you have any specific concerns or questions?

By signing this consent form

Patient signature: ______________________________________ Date //

Doctor’s signature: __________________________________________

Doctor’s name: ______________________________________ //

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