Coil Questionnaire

This form must be completed by the person requesting the procedure. if an appointment with an interpreter is required to help someone completing this questionnaire then this can be arranged by phoning 01444 233450.

What is your name?
What is your date of birth?
For example 31 03 1980
What is your sex? (As recorded on your medical records)
The one used to register to your GP
What is your email address?
Anyone else with access to your email address may see responses sent to you

Request Details

Home Address (including postcode)
Are you happy to receive texts about coil fitting on the number you have provided?
Are you registered with Silverdale Practice?
What are you requesting an appointment for?

Medical History

Do you suffer from heart problems?
Do you have epilepsy or seizures?
Have you had a recent organ transplant?
Have you had ovarian, cervical, womb or breast cancer?
Do you currently suffer with liver problems?
Do you have any other long-term conditions?
Are you currently taking hormone replacement therapy or do you plan to start this?

Pregnancy History

Have you been pregnant previously?
Have you ever been told that you have an issue with your womb (e.g. fibroids, heart-shaped womb, separate womb)?
Have you had any pelvic surgery or surgery on the womb including endometrial resection or ablation (removal of the lining of the womb)?
Have you had any procedures on your cervix (other than routine cervical smears)?

Contraception

-Please arrive at your appointment with a urine sample, bottle of water and a sanitary pad.

-Please take some painkillers an hour before the procedure (either Ibuprofen 400mg with or after food or Paracetamol or both as long as you are not allergic to these as some women experience discomfort, described as period like cramps during coil insertion.

Please tick if any of the below apply to you. Please continue your current method for contraception until the coil fitting and for 7 days after:
Please tick if any of the below apply to you, then please abstain from sexual intercourse or use a condom every time for at least 3 weeks before your appointment and for 7 days after:

Periods

Do you have any bleeding in between your periods?
Do you bleed after sex?
Have your periods recently changed to become much heavier than usual, passing clots or flooding through towels/tampons?

Infection

If you answer yes to any of the questions in the next section, you will need to have STI (sexually tramsmitted infection) testing for gonorrhoea and chlamydia before having your coil fitted and have the results available at least a week before your coil fit appointment.
Are you sexually active and aged under 25?
Have you had a new sexual partner in the last 3 months?
Have you had more than one sexual partner in the last year?
Do you have a regular sexual partner who has other sexual partners?
Do you have a history of sexually transmitted infections or a recent contact of someone with an sexually transmitted infection?
Are you concerned that your sexual partner may have a sexually transmitted infection?
Do you have any pelvic pain, vaginal discharge or change in bleeding pattern?

Advice Pre Procedure

– Please arrive at your appointment with a urine sample, bottle of water and a sanitary pad.

– Please take some painkillers about an hour before the procedure to help reduce any discomfort. You can take Ibuprofen 400mg with or after food, or Paracetamol if you are not allergic to either. Some women experience period like cramps during coil insertion, so this can help ease those symptoms.

Some women can feel a little faint during and after the fitting. Please have a light meal and something to drink before you come to help avoid this. You may wish to have a friend or relative travel with you or drive you home after the appointment. There will be a doctor and a nurse present. Children and babies cannot be present during the procedure. If children are brought to the appointment the procedure will be cancelled. Please wear loose, comfortable clothes and footwear for your appointment. Remember, you can change your mind about having a coil fitted at any time.

The Fitting Process

Please allow an hour for the appointment. If at any stage you change your mind about the fitting, the procedure can be stopped. The process of fitting a coil is similar to what happens with a smear test but takes longer and can be more uncomfortable. A vaginal examination will be undertaken and then the coil fitted. You may feel some discomfort, but this varies from person to person. The doctor and nurse will do their best to reassure you and make the procedure as pleasant as it can be. You will be taught how to check your threads. After the procedure, you will be advised to sit in the waiting room for 10-15 minutes to make sure you continue to feel well. Please ensure you have no major commitments afterwards as you may need to take it easy and relax for the rest of the day.

After the Fitting

Please refrain from exercise for 24 hours after the procedure. We advise that you abstain from sexual intercourse for seven days due to risk of infection. If not abstaining please use additional contraception such as condoms for seven days. You may experience bleeding or cramping. Continue with regular painkillers if required. If the pain is more uncomfortable than a period talk to a doctor. Avoid tampons for the first three weeks, but thereafter it is ok to use them. If you have any concerns after your coil fitting, please do not hesitate to contact the surgery for advice.

Possible Risks

  • Discomfort/dizziness/fainting on insertion
  • Failure rate resulting in pregnancy is less than 0.2%
  • Infection
  • Damage to the cervix or womb is 1 in every 500 women.
  • Altered vaginal bleeding, which usually settles within six months.
  • Hormonal effects, including greasy skin, bloating and breast tenderness.
  • Expulsion 1 in every 20 (coil comes out of the womb) or displacement (change of position)

Before you attend, please ensure that you are aware and agree with the following statements:

  • I have completed this form myself
  • I have read the information about the Coil
  • I have followed the advice about contraception and not having sex for 3 weeks before the procedure, and for 7 days after
  • I have checked whether I need a sexual transmitted infection screen
  • If I need to have an sexually transmitted infection screen, I will ensure I have my results before I attend my fitting appointment
  • I understand that the clinician will not fit the Coil if they are concerned that I may be pregnant
  • I understand that the Coil may fail as contraception in 2-5 women in every 1000 that have them fitted. If it does fail there is a risk that the pregnancy will not be in the womb (ectopic pregnancy)
  • I understand that there is a risk of infection of 1 per 100 women in the first few weeks after insertion
  • Symptoms of infection include, worsening pain, fever, offensive vaginal discharge. If any of these symptoms occur please seek urgent medical attention.
  • I understand that the Coil will not protect me against sexually transmitted infections and condoms are recommended too, especially if I have a new sexual partner
  • I understand that there is a 1 in 20 chance of the device falling out (expulsion) or displacement
  • I understand that the risk of uterine perforation (hole in the womb) is 1-2 per 1000 women. In breastfeeding women, the risk is 6-12 per 1000 women
  • I understand that sometimes the Coil cannot be refitted after removal due to cervical spasm and if this happens a further appointment may be offered
  • I understand my bleeding pattern may change
  • I will have breakfast and a drink prior to the fitting appointment
  • I will bring a bottle of water to the appointment
  • I will not being children/babies to the appointment
  • I understand that if I wish to take painkillers, I should do so an hour before the appointment
  • I understand that I am likely to bleed after the fitting and will need a sanitary pad
  • I can use my menstrual cup or tampons from 3 weeks after fitting to allow the threads to settle
  • It is common to have period pain after fitting and some I may need to rest
Confirmation