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Contraceptive Implant Placement

  • Author: Megan A Brady, MD; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Mar 10, 2014
 

Background

The contraceptive implant is a popular form of reversible long-acting contraception. Norplant, the first contraceptive implant, became available in 1983[1] but was later removed from the market owing to patient dissatisfaction with adverse effects that ultimately led to several lawsuits against the manufacturer. It was also difficult to remove.[2]

The currently available implants, the Nexplanon, and its first-generation model, the Implanon, contain the progestin etonogestrel. The advantage of this form of contraception is that it provides effective long-term contraception that does not depend on the recipient’s daily compliance.

The most recent generation of implantable devices is the most effective form of birth control available and can usually be inserted by trained practitioners in less than one minute.[3, 4, 5, 6] The pregnancy rate with the implant is 0.05%, which is slightly lower than the levonorgestrel intrauterine device (0.2%) and the copper intrauterine device (0.6%).[7, 8]

A release rate of 25-30 µg/day of etonogestrel is required to suppress ovulation. With this device, the initial rate of release is 60-70 µg/day, which slowly decreases over time, to about 30 µg/day. Maximum serum levels are attained the fourth day after insertion, on average.

After removal of the implant, etonogestrel serum levels become undetectable within one week.[1, 5, 9]

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Indications

The contraceptive implant is currently approved for contraception in women, including nulliparous women, adolescents, and breastfeeding mothers.[7] It has been studied for use in women with pelvic pain and endometriosis; additional uses of this device are a topic of ongoing research.[10, 11]

The contraceptive implant now available is a levonorgestrel implant, which works by the same mechanism as other progesterone-only methods: by inhibiting ovulation, thinning the endometrium, and thickening cervical mucus.[4, 12]

The US Medical Eligibility Criteria for Contraceptive Use, published by Centers for Disease Control and Prevention, guides practitioners about the safety of contraceptive implant use in patients with other medical conditions. The contraceptive implant is safe or the risks of harm are thought to be outweighed by the contraceptive benefit in the following situations:[7]

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Contraindications

The contraceptive implant should not be used in the following situations:

  • Pregnancy
  • Liver disease, including severe cirrhosis or liver tumors
  • Personal history of breast cancer
  • Undiagnosed abnormal vaginal bleeding
  • Allergy or hypersensitivity to any of the implant materials
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Outcomes

The pregnancy rate with the implant is 0.05%, which is slightly lower than the levonorgestrel intrauterine device (0.2%) and the copper intrauterine device (0.6%).[7, 8]

Potential complications

The most common procedural complication is pain at the insertion site, which occurs in less than 3% of users, according to one study.[6] Pain is usually transient and resolves with time. Other uncommon complications include the implant being retained in the needle applicator, bleeding or redness at the insertion site, and hematoma formation.[6, 5] Bruising after insertion is possible and should resolve within a few days.

Side effects of the levonorgestrel implant, unrelated to implant insertion, have been reviewed in an analysis of 11 major international clinic trials that include 942 subjects. The most common reason (13.6%) for a woman to discontinue use of the implant was an adverse side effect such as headache, weight gain, acne, breast pain, emotional lability, and abdominal pain. Another 11% of women cite undesirable bleeding irregularities as their reason for discontinuation. The most common irregularity was infrequent bleeding (33.3%), followed by amenorrhea (21.4%), prolonged bleeding, and frequent bleeding.[6]

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Contributor Information and Disclosures
Author

Megan A Brady, MD Fellow in Female Pelvic Medicine and Reconstructive Surgery, Loyola University Hospital

Megan A Brady, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urogynecologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

David Chelmow, MD Leo J Dunn Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

References
  1. Meirik O, Fraser IS, d'Arcangues C. Implantable contraceptives for women. Hum Reprod Update. 2003 Jan-Feb. 9(1):49-59. [Medline].

  2. MedWatch The FDA Safety Information and Adverse Event Reporting Program Accessed 2-13-12. Norplant. [Full Text].

  3. Levine JP, Sinofsky FE, Christ MF. Assessment of Implanon insertion and removal. Contraception. 2008 Nov. 78(5):409-17. [Medline].

  4. Croxatto HB, Urbancsek J, Massai R, Coelingh Bennink H, van Beek A. A multicentre efficacy and safety study of the single contraceptive implant Implanon. Implanon Study Group. Hum Reprod. 1999 Apr. 14(4):976-81. [Medline].

  5. Funk S, Miller MM, Mishell DR Jr, Archer DF, Poindexter A, Schmidt J, et al. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contraception. 2005 May. 71(5):319-26. [Medline].

  6. Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril. 2009 May. 91(5):1646-53. [Medline].

  7. U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep. 2010 Jun 18. 59:1-86. [Medline].

  8. Mommers E, Blum GF, Gent TG, Peters KP, Sørdal TS, Marintcheva-Petrova M. Nexplanon, a radiopaque etonogestrel implant in combination with a next-generation applicator: 3-year results of a noncomparative multicenter trial. Am J Obstet Gynecol. 2012 Nov. 207(5):388.e1-6. [Medline].

  9. Wenzl R, VanBeek, A, Schnabel P, Huber J. Pharacokinetics of Etonogestrel Released from the Contraceptive Implant Implanon. Contraception. 1998. 58:283-288. [Medline].

  10. Shokeir T, Amr M, Abdelshaheed M. The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet. 2009 Sep. 280(3):437-43. [Medline].

  11. Walch K, Unfried G, Huber J, Kurz C, van Trotsenburg M, Pernicka E, et al. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis--a pilot study. Contraception. 2009 Jan. 79(1):29-34. [Medline].

  12. Mäkäräinen L, van Beek A, Tuomivaara L, Asplund B, Coelingh Bennink H. Ovarian function during the use of a single contraceptive implant: Implanon compared with Norplant. Fertil Steril. 1998 Apr. 69(4):714-21. [Medline].

  13. Higginbotham S. Contraceptive considerations in obese women: release date 1 September 2009, SFP Guideline 20091. Contraception. 2009 Dec. 80(6):583-90. [Medline].

  14. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011 Jul. 118(1):184-96. [Medline].

  15. Implanon (etonogestrel implant) [package insert]. Merck. 2006, 2009. Available at [Full Text].

  16. Taneepanichskul S, Reinprayoon D, Thaithumyanon P, Praisuwanna P, Tosukhowong P, Dieben T. Effects of the etonogestrel-releasing implant Implanon and a nonmedicated intrauterine device on the growth of breast-fed infants. Contraception. 2006 Apr. 73(4):368-71. [Medline].

  17. Brito MB, Ferriani RA, Quintana SM, Yazlle ME, Silva de Sá MF, Vieira CS. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009 Dec. 80(6):519-26. [Medline].

  18. Nexplanon, Highlights of Prescribing Information [package insert]. Whitehouse Station, NJ: Merck. 2011. Available at [Full Text].

  19. Croxatto HB. Mechanisms that explain the contraceptive action of progestin implants for women. Contraception. 2002 Jan. 65(1):21-7. [Medline].

 
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An Implanon applicator and its parts
Patient's wrist is parallel to her ear or her hand is positioned next to her head.
The insertion site, which is at the inner side of the nondominant upper arm about 8cm above the medial epicondyle of the humerus.
Insert only the tip of the needle with the beveled side up into the insertion site at a 20 degree angle.
Tent the skin with the needle as you fully insert it into the subdermal space, keeping the needle parallel to the surface of the arm.
Break the seal of the applicator by pressing the obturator support
Turn the obturator 90° in either direction with respect to the needle.
While holding the obturator fixed in place on the arm, fully retract the cannula.
The practitioner and patient should palpate the implant immediately after insertion.
The transparent protection cap should be removed by sliding it horizontally away from the device.
With your free hand, use countertraction on the skin as you insert the needle at a 30 degree angle.
Once the needle has punctured the skin, hold the applicator horizontal to the skin, and tent the skin upwards as you slide the entirety of the needle into the subdermal space.
While holding the applicator in place, unlock the purple slider with your index finger by pushing the slider downwards and backwards until it locks.
At this point the needle is inside the applicator and the applicator can be removed from the field.
 
 
 
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