(Published July 2008)
Insertion and Removal: Timing and Tips
Only health care providers who receive training from the manufacturer are authorized to insert the single-rod implant. Insertion and removal techniques are not difficult to learn. Because the single-rod implant involves insertion of only one rod and no incision, insertion is quick (less than one minute) and relatively painless.1 The only equipment required for insertion are the components supplied with the implant. Removal usually takes less than three minutes and only requires a scalpel and a pair of mosquito forceps.
Timing of implant insertion is important in order to avoid placing the device in women who are pregnant. The optimal time depends on the woman’s recent medical and contraceptive history. Consider the scenarios below before selecting the optimal timing:
No preceding hormonal contraceptive use in the past month
- Counting the first day of menstruation as Day one, the single-rod implant must be inserted between days one through five, even if the woman is still bleeding.
Switching from a combination hormonal contraceptive
- Anytime within seven days after the last active combined (estrogen plus progestin) hormonal oral contraceptive tablet
- Anytime during the seven-day ring-free period of the contraceptive ring (NuvaRing®)
- Anytime during the seven-day patch-free period of a transdermal contraceptive system (Ortho Evra®)
Switching from a progestin-only method
There are several types of progestin-only methods. In women who are currently using a progestin-only method, the single-rod implant insertion must be performed as follows:
- Any day of the month when switching from a progestin-only pill (do not skip any days between the last pill and insertion of the single-rod implant)
- On the same day as contraceptive implant removal
- On the same day as removal of a progestin-containing intrauterine contraceptive
- On the day when the next contraceptive injection would be due or in the two weeks before the next injection is due
Following first trimester abortion or miscarriage
- The single-rod implant may be inserted immediately following a complete first trimester abortion.
If the implant is not inserted within five days following a first trimester abortion:
— Counting the first day of menstruation as Day one, the single-rod implant must be inserted between days one through five, even if the woman is still bleeding.
|Reminders about implant insertion…|
Following delivery or a second trimester abortion
- The single-rod implant may be inserted between 21 to 28 days post-partum if not exclusively breast feeding or between 21 to 28 days following second-trimester abortion. If more than four weeks have elapsed from either the delivery or termination, pregnancy should be excluded and the woman should use a non-hormonal method of birth control during the first seven days after the insertion. If the patient is exclusively breast feeding, the implant should be inserted after the fourth postpartum week.
Insertion of the Single-Rod Implant
The components of the single-rod implant insertion system are shown in Figure 8. The implant rod is located inside the needle of the cannula and should be visible as a white body inside the needle tip. Note that the implant rod can drop out of the applicator if it is tipped downward.
- Place the patient in a supine position with the non-dominant arm flexed at the elbow and externally rotated.
- The correct insertion site is subdermal in the groove between the biceps and triceps approximately six cm to eight cm above the medial humeral condyle.
- Keep the applicator pointing upward until insertion to prevent the rod from falling out of the applicator.
- After removing the applicator from the pack, visualize the rod inside the needle and then tap the base of the applicator with the needle pointed up until the rod disappears.
- Insert the needle at no more than a 20-degree angle until the skin is penetrated, then lower the applicator until it is parallel to the arm.
- Palpate to confirm placement of the implant. An implant may be impalpable because of failed insertion technique resulting in non-insertion, deep insertion, or migration, which is very rare.
- If there is doubt as to the correct placement of the rod, non-hormonal contraception should be used and the rod must be located.
|Evans R, Holman R, Lindsay E. Migration of Implanon®: two case reports. J Fam Plann Reprod Health Care. 2005:31(1):71-72.
Ismail H, Mansour D, Singh M. Migration of Implanon. J Fam Plann Reprod Health Care. 2006:32(3):157-159.
Mavani M, Robinson C. Clinical challenge with Implanon® removal: a case report. J Fam Plann Reprod Health Care. 2005;31(2):161-162
Singh M, Mansour D, Richardson D. Location and removal of non-palpable Implanon® implants with the aid of ultrasound guidance. J Fam Plann Reprod Health Care. 2006:32(3):153-156.
Walling M. How to remove impalpable Implanon® implants. J Fam Plann Reprod Health Care. 2005;31(4):320-321.
Wechselberger G. Wolfram D, Pulzl P, et al. Nerve injury caused by removal of an implantable hormonal contraceptive. Am J Obstetric Gynecol. 2006; 195:323-326.
No back-up barrier protection is needed if the implant is inserted as recommended in Insertion Timing. Pregnancy should be ruled out in the case of amenorrhea, pregnancy symptoms, or pelvic pain. Providers should be sure to discuss the need for barrier protection if the patient is at risk for sexually transmitted infections (STIs) or human immunodeficiency virus (HIV).
Single-rod Implant Removal
The single-rod implant must be removed within 3 years of insertion. Only providers trained in removal of the single-rod implant should perform removal. Removing the implant is not complex, but here are a few tips to make it easier.
- Before removal, the implant rod must be located, either by palpation or imaging.
- Inject the local anesthetic under or beneath the rod to prevent displacing or obscuring it.
- Make an incision in the longitudinal axis of the arm
over the distal end of the implant.
No Higher Risk of Litigation There is a perception among some providers that contraceptive implants are associated with a high risk of litigation for providers. However, no implants have been withdrawn from the market by any regulatory agency. The majority of claims against the multiple-rod implant (Norplant®) were against the manufacturer, relating to design defects and inadequate warnings, not manufacturing defects or individual providers. Even with aggressive recruitment by personal injury lawyers, only approximately five percent of all Norplant users joined lawsuits, and the courts denied class action status for the plaintiffs. The vast majority of the 14,000 cases were dismissed, and a small number were settled out of court for an average of $1,400. A minority of claims were against clinicians, and were related to insertion, removal, infection, and scarring.4
Encapsulated implants may require further dissection. Sharp or blunt dissection of the fibrous capsule is required if the rod is encapsulated, and then the rod can be removed.
- If the implant cannot be pushed to the opening of the incision, the forceps can be inserted into the incision to grasp the implant.
- Curved mosquito forceps are recommended to grasp the implant after the incision is made.
- A new implant can be inserted through the same incision or in the opposite arm if continued use of an implant system is requested.
- Problems may arise when the implant is non-palpable. Non-palpable implants may be caused by an unrecognized non-insertion, deep placement at the time of insertion, significant
weight gain, or migration after insertion.
The approach for non-palpable rods is to locate the implant either by ultrasound or magnetic resonance imaging (see Additional Reading). Attempts to remove a non-palpable implant blindly might lead to scarring, nerve or vessel damage, and medico-legal action.3
- Zheng SR, Zheng HM, Qian SZ, Sang GW, Kaper RF. A randomized multicenter study comparing the efficacy and bleeding pattern of a (Implanon®) and a six-capsule (Norplant®) hormonal contraceptive implant. Contraception. 1999;60:1-8.
- Funk S, Miller MM, Mishell DR Jr, Archer DF, Poindexter A, Schmidt J, Zampaglione E; The Implanon US Study Group. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contraception. 2005 May;71(5):319-26.
- Piessens SG, Palmer DC, Sampson AJ. Ultrasound localisation of non-palpable Implanon. Aust N Z J Obstet Gynaecol. 2005 Apr;45(2):112-6.
- Grimes DA. Contraceptive implants and injectables: recent developments. The Contracept Rep. 2000;10(6):26-28.
About Audrey Kelly, PharmD