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Have you experienced one or more of the following with your Essure device? Please tick all that apply:
the device perforating the fallopian tube, uterus or other organs, such as the bowel
migration or movement of the device out of the fallopian tube
the device being expelled from the fallopian tube or out of the body
breaking or fragmenting of the device
corroding of the device
fatiguing of the device
had more than two Essure devices inserted in the body
leaching of nickel or other metals from the device into the body
have undergone testing for nickel or other metals in the body
none of the above
not sure
Have you had Essure removed?
Yes
No
On what date was Essure removed, by which doctor, and at which hospital?
How was Essure removed? Please tick all that apply
Removal of devices only – fallopian tubes and uterus left in
Unilateral salpingectomy (one fallopian tube removed)
Bilateral salpingectomy (both fallopian tubes removed)
Hysterectomy (removal of uterus) with ovaries conserved
Hysterectomy (removal of uterus) with ovaries removed
Uterus removed only but fallopian tubes conserved (hysterectomy)
Removal of one or more fallopian tubes followed by a hysterectomy or further surgery at a later date
Other:
Other Value
If you underwent a hysterectomy, was this:
Abdominal hysterectomy
Laparoscopic hysterectomy
Unsure
Not applicable – did not have hysterectomy
If you had more than one surgical procedure listed above, please state the rough date on which each took place
Why did you have Essure and/or organs removed? Please tick all that apply
I didn’t want to suffer the pain any longer
I didn’t want to suffer the irregular/excessive menstrual bleeding any longer
I was concerned about nickel or other toxins
I didn’t want to suffer other symptoms any longer
The device had migrated, perforated, broken, fragmented, been expelled, corroded, and/or leached metals into the body and required removal
Other:
Other Value
Did your doctor perform any of the following tests before and after Essure was removed? Please tick all that apply
Ultrasound – before removal
Ultrasound – after removal
Nickel or other metal test – before removal
Nickel or other metal test – after removal
Inflammation markers test – before removal
Inflammation markers test – after removal
None of the above
Have your symptoms changed since Essure was removed?
Yes
No
If Yes, please tick all boxes that apply to you
All of my symptoms resolved
Most of my symptoms resolved
Some of my symptoms resolved
None of my symptoms resolved
My symptoms resolved immediately
My symptoms resolved within two months
My symptoms resolved after several months
My symptoms resolved after a year or more
If Essure has not been removed, is it more probable than not that you will have Essure removed in the future?
Yes
No
Please tick the boxes that apply to you
I had an ablation at the same time as Essure insertion
I had an ablation while Essure was inserted but not on the same day as Essure insertion
I had an ablation at the time Essure was removed or within 6 weeks after Essure was removed
I did not have an ablation while Essure was present
Were you diagnosed with a gynaecological condition before your Essure implant, e.g. endometriosis or adenomyosis?
Yes
No
If Yes, please state the condition
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