Soheil Hanjani MD FACOG FACS

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					Soheil A. Hanjani, MD, FACOG, FACS                          Obstetrics & Gynecology
                                                            830 Oak Street, Suite 201W        199 Reedsdale Road
                                                            Brockton, MA 02301                  Milton, MA 02186
                                                            (508) 583-4961                      (617) 696-0695
                                                            Fax (508) 583-4732                   (617) 696-2216
                                                            Hanjani@medscape.com


Hysteroscopic tubal occlusion (Essure) – a non-incisional permanent birth control technique
for the office.

We are now able to offer you the latest technology in permanent birth control performed right in the office – unlike
surgical tubal ligation this office procedure does not require any incisions and can easily be performed in our office.
In addition, Essure is a noninvasive procedure that allows women to return home about 30 minutes after the
procedure is completed and return to usual activity the following day.

During the Essure procedure, a soft micro-insert is placed into each fallopian tube through the cervix using a small
catheter. Once in place, the insert stimulates the body’s natural tissue growth in and around the micro-insert,
forming an occlusion, or blockage, in the fallopian tube. This results in permanent sterilization.

The FDA approved Essure several years ago and among women who have had Essure procedure done no
pregnancies have occurred. However, like all other forms of birth control, Essure is not expected to be 100%
effective. Especially important is the use of another birth control method for the first three months following the
procedure. For confirmation, after three months, a special x-ray will be done to ensure that both fallopian tubes are
occluded and the sterilization is confirmed.

The procedure is comfortably performed in the office using local anesthesia and lasts 10 minutes.

Procedure Information:

Before the procedure: You ideally should not be bleeding on the day of the procedure. Light spotting is usually
okay, but if you are having any heavier flow please contact the office beforehand. Also, ideally, you should be on a
hormonal birth control, pill, patch, or Depo-Provera.

Take one sedative tablet prescribed one hour before your procedure. Someone should drive you to the office and
take you home as driving yourself is not allowed. On the day of procedure, plan to arrive at least 30-45 minutes
before the scheduled time of the procedure.

A urine specimen will be requested to assure a negative pregnancy test.

You will be given an anti-inflammatory medication injection 30 minutes prior to the procedure. It is important that
you let us know if you have any medication allergies. We will have you then rest until the time of the procedure.

During the procedure:

Initially you will be given a local anesthetic for the procedure, which usually will feel like a small sting, as the
cervix is injected. We will then wait 5-10minutes for the numbing medicine to work fully.

You will be awake for the procedure, and the nurse and I will make every effort to assure your comfort.

You may feel some slight cramping at times during the procedure. The average time for the procedure is 10
minutes. Feel free to watch on TV as we do the procedure!




Hanjani 8/2009                                              1
After the procedure:

You will be given a completed patient ID card before leaving. Expect to spend around 30 minutes recovering after
the procedure in the office before going home. Someone should drive you home.

Post procedure, usually anti-inflammatory such as Motrin or Advil will suffice. However, if you feel
uncomfortable, do not hesitate to ask for a prescription. You may experience some mild cramping or spotting after
the procedure for a couple of days. This is normal. If you do have any significant pain or bleeding or concern, do
not hesitate to contact us.

During the next three months, it is important to use another form of contraception. You should make a follow-up
appointment for six weeks. Following that, another appointment for a test called hysterosalpingogram (HSG) will
be made, which is an x-ray test in the hospital to confirm the tubes are successfully blocked.

Consent

I have requested a permanent form of birth control. My physician has counseled me in regard to my options and I
desire the in-office Essure procedure. I understand this procedure is a non-incisional minor surgical procedure that
involves placing micro-inserts into each of the fallopian tubes. This is performed by using hysteroscopy. Once the
micro-inserts are in place, the body tissues grow into the inserts thus blocking the tubes.

Through discussion with my physician, I understand the risks during the procedure, although rare, include the
following: Pain, vaginal bleeding, nausea/vomiting/fainting during or after the procedure, infection, reaction to
local anesthetic, perforation of the tubes or uterus or other organs, damaged micro-inserts, failure to place micro-
inserts in correct position, undiagnosed pregnancy at the time of procedure with miscarriage risk, over absorption of
fluid.

My physician has discussed the risks following the Essure procedure, which include failure to obtain tubal
occlusion at three months, pregnancy, ectopic pregnancy, change in menstrual cycle, and pelvic/back/abdominal
pain.

I understand that an alternative birth control method must be used for three months following the procedure, and at
the end of the three months, I must have a hysterosalpingogram (HSG) to make sure the tubes are blocked and the
devices are at the correct position.

I am aware that after the Essure procedure, certain devices used to treat heavy uterine bleeding cannot be utilized. I
also understand that it is important for me to alert my health care providers that I have an Essure procedure.

I understand this procedure is permanent, but there is no guarantee of success. I also understand that it cannot be
reversed, and I again understand all my alternative options.

The above has been explained to me to my satisfaction and understanding, and all my questions have been
answered.

I authorize my physician to perform the Essure procedure.

Patient signature        __________________________________                  Date _____________________


Physician signature      __________________________________




Hanjani 8/2009                                            2

				
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