Contraceptive Implant Placement

The contraceptive implant is a popular form of long-acting reversible contraception (LARC). 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 implant, Nexplanon, is a rod that contains the progestin etonogestrel and is intended for subdermal implantation in the non-dominant arm. It is the second-generation of the device; the first-generation was called Implanon. The currently available device differs from its first-generation counterpart in that the implant itself is radiopaque and its applicator design is improved so as to prevent placement deeper than the intended subdermal location.

The advantage of an implantable form of contraception is that it provides effective long-term contraception that does not depend on the recipient’s daily compliance. The implant has become a popular choice among adolescents and young women, and is appropriate for both nulliparous or parous women.[3]

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.[4, 5, 6, 7] 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%).[8, 9]

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, 6, 10]

The contraceptive implant is currently approved for contraception in women, including nulliparous women, adolescents, and breastfeeding mothers.[8]  The implant is approved for immediate postpartum use. It may be inserted as soon as 10 minutes after placental delivery, thus providing safe and effective reversible contraception prior to hospital discharge. The insertion technique does not differ for immediately postpartum placement. [11]

The contraceptive implant is an etonorgestrel implant, which works by the same mechanism as other progesterone-only methods: by inhibiting ovulation, thinning the endometrium, and thickening cervical mucus.[5, 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[8] :

• Cigarette smoking

• Current infection with or history of sexually transmitted diseases or pelvic inflammatory disease

• Obesity (Note: the contraceptive implant has been studied in women up to 130% of ideal body weight; the effectiveness of the implant in obese women is still being investigated.[10, 13] )

• Hypertension

• Hyperlipidemia

• History of deep vein thrombosis or pulmonary embolism

• Rheumatoid arthritis

• Anemia

• Mild cirrhosis

• Epilepsy

• Thyroid disease

• Diabetes mellitus

• History of bariatric surgery

• Breastfeeding[14, 15]

• Postabortion (first or second trimester)

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

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%).[8, 9]

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.[7] 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.[7, 6] Bruising after insertion is possible and should resolve within a few days.

Side effects of the etonorgestrel 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.[7]

Patients who desire a contraceptive implant should be counseled on other birth control methods before choosing this device. The practitioner should show the patient the implant palpation simulator that Merck provides to clinicians so her expectation of how the implant feels after insertion is realistic.

Elements of informed consent

Informed consent should be obtained. The practitioner should explain the implant’s efficacy, complications of insertion, likely changes in bleeding pattern, and why other women have chosen to stop using this form of birth control.

Pregnancy should always be ruled out with a urine pregnancy test prior to contraceptive implant placement. Optimal timing of insertion of the implant to minimize chance of pregnancy is as follows:[16]

• If no previous method of contraception is being used, insert between days 1 and 5 of menstrual cycle

• If using oral combined hormonal pills, insert during the hormone-free week

• If using a progestin-only pills, insert at any time

• If using injectable contraception (Depo Provera), insert when next injection is due

• If inserting after a first- or second-trimester abortion, including septic abortion, insert within 5 days

• If inserting after use of a contraceptive implant, remove old implant and immediately insert new implant during the same procedure[17]

• If inserting after use of the transdermal patch or vaginal ring, insert on same day as those methods are removed

• If inserting after childbirth in a breastfeeding mother, insertion at any time is acceptable, either within 24-48 hours of delivery or at the 6-week postpartum visit; studies have not found differences in milk production or content, continuation of breastfeeding, or infant growth based on these different time windows of insertion[14, 15]

• If the implant is not inserted as directed, the patient should use a barrier method for 7 days

The practitioner should have the following available for the office procedure:

• Sterile gloves

• Disposable sterile implant applicator

• Local injectable anesthetic, such as 1% lidocaine with or without epinephrine

• 2-mL syringe

• Needle (18 gauge) for drawing up the anesthetic

• Needle (25 gauge, 1.5 cm) for injecting the anesthetic

• Antiseptic solution such as povidone iodine or chlorhexidine

• A sterile marking pen, if desired

• Adhesive dressing, such as Steri-Strips

• Pressure dressing, like Kerlix

Nexplanon is manufactured by Merck and had been distributed since about 2012. Its first-generation model, the Implanon, became available in the United States in 2006.[4] The implant is a single-rod nonbiodegradable device that measures 4 cm in length and 2 mm in diameter. It contains a core of 68-mg etonogestrel (3-ketodesogestrel), which is the biologically active metabolite of desogestrel. The rod is made of the plastic ethylene vinyl acetate (EVA) copolymer covered by a thin EVA membrane that slowly releases hormone over 3 years.

Anesthesia

After cleaning the insertion site with antiseptic, sterile gloves should be worn by the practitioner. In preparation for local anesthesia, 1-2 mL of 1% lidocaine with or without epinephrine should be drawn into a syringe with an 18-gauge needle. Then, a smaller 25-gauge needle should be applied to the syringe. The lidocaine should be injected along the planned subdermal insertion site of the implant to both hydrodistend and anesthetize the space where the implant is to be inserted (see image below).

Positioning

The medial side of the upper nondominant arm should be exposed to the practitioner. This is best accomplished by having the patient lie on her back on an examination table with her arm flexed at her side so her hand lies near her head, palm facing the ceiling (see image below).

The implant should be inserted 8 -10 cm (3-4 inches) above the medial epicondyle of the humerus. It should be inserted subdermally, avoiding the sulcus between the biceps and triceps muscles, which contains a neurovascular bundle. Some practitioners like to mark the approximate insertion site, as well as a few centimeters proximal to that as a guiding mark. When actually inserting the needle, do not place the needle directly through this marking to avoid tattooing of the skin.

After insertion and confirmation of proper placement of the implant by practitioner and patient palpation, no further monitoring is necessary. Acetaminophen or ibuprofen is an acceptable option for postprocedural pain. A patient user card provided in the device packaging should be filled out, indicating the 3-year removal date, and given to the patient.

The Nexplanon contains barium sulfate and is radiopaque. If nonpalpable, it can be identified with radiography or CT scanning.

If the first-generation Merck contraceptive implant, Implanon, cannot be palpated after insertion or at the time of removal, it can be localized with high-resolution ultrasonography (>10 MHz) or MRI.[4]

Near-infrared light has also been used to locate nonpalpable etonogestrel implants.[18]

The Nexplanon should be removed from its packaging and the applicator held between the thumb and forefingers at the site of the textured area. The transparent protection cap should be removed by sliding it horizontally away from the device (see image below). The implant can be seen by looking into the needle tip. The clinician should sit during this procedure to better view the applicator from the side rather than looking down on the device while standing.

With the free hand, the practitioner uses countertraction on the skin while inserting the needle at a 30° angle (see image below).

Once the needle has punctured the skin, hold the applicator horizontal to the skin, and tent the skin upward as the entirety of the needle is slid into the subdermal space (see image below).

While holding the applicator in place, the purple slider is unlocked with the clinician’s index finger by pushing the slider downward and backward until it locks (see image below).

At this point, the needle is inside the applicator and the applicator can be removed from the field. The Nexplanon should immediately be palpated to ensure proper placement, and the applicator needle should be examined to verify that the implant has not been retained. An adhesive dressing should be placed over the insertion site, and the implant should be palpated by the patient before dressings are applied (see image below).

The goals of pharmacotherapy are to suppress ovulation and to prevent pregnancy.

Class Summary

Agents in this class prevent pregnancies.

Etonogestrel (Implanon, Nexplanon)

Etonogestrel is the active metabolite of desogestrel that suppresses ovulation, inhibits endometrial proliferation, and increases viscosity of cervical mucus.

 

Class Summary

Local anesthetics block the initiation and conduction of nerve impulses.

Lidocaine (Xylocaine)

Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. After cleaning the insertion site with antiseptic, sterile gloves should be worn by the practitioner. In preparation for local anesthesia, 1-2 mL of 1% lidocaine with or without epinephrine should be drawn into a syringe with an 18-gauge needle. Then, a smaller 25-gauge needle should be applied to the syringe. The lidocaine should be injected along the planned subdermal insertion site of the implant to both hydrodistend and anesthetize the space where the implant is to be inserted.