Clinician satisfaction and insertion characteristics of a new applicator to insert radiopaque Implanon: an open-label, noncontrolled, multicenter trial

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Pregnancies associated with etonogestrel implants in the UK: comparison of two 5-year reporting periods

OBJECTIVES

(1) To identify pregnancies associated with the use of the contraceptive implants Implanon and Nexplanon in the UK during two 5-year reporting periods. (2) To classify the possible reasons for device failure in cases reported for each implant. (3) To examine any differences between reasons for pregnancies associated with these products.

STUDY DESIGN

Extraction of data from the UK spontaneous reporting system for adverse drug reactions in relation to etonogestrel implants. Reports indicating pregnancy were identified for the periods 2005-2009 (Implanon) and 2012-2016 (Nexplanon). Possible reasons for failure of the method in each reported case were assigned to one of eight predetermined categories.

RESULTS

After exclusions, 229 Implanon and 234 Nexplanon cases contained sufficient information for analysis. True method failures accounted for a majority of the pregnancies in those using contraceptive implants (58%); the next most common cause was missing implants (26% of pregnancies). In all categories of cases, there was no difference in frequency of pregnancy when the two time periods were compared.

CONCLUSIONS

There is still potential for greater avoidance of pregnancies associated with etonogestrel implant use.

IMPLICATIONS

This study underscores the continuing need for taking a full drug history, timing the insertion on days 1-5 or according to recommended quick starting routines and palpating the arm after implant insertion.

Experiences of localization and removal of non-palpable subdermal contraceptive implants with ultrasound

Objective

The aim of this study was to present experiences in localization and removal of non-palpable subdermal contraceptive implants with ultrasonography.

Methods

Medical records from January 1, 2016, to April 30, 2018, were retrospectively reviewed for 21 patients who were referred to a single institution and had an impalpable implant despite following the removal instruction. In all the cases, more than one attempt was made to remove the implant before referral. The rod was detected using radiography and ultrasonography. In all the cases, localization of the single implant was achieved with ultrasonography. The distal depth of the rod was measured, and skin marking was made following the echogenicity. The implants were subsequently removed under anesthesia.

Results

In 18 cases, the rods were localized using ultrasonography and successfully removed under local anesthesia. In the other three cases, removal with local anesthesia failed. Although the rod was detected successful with ultrasonography, the implants were removed under general anesthesia in the operating room. The depth from skin to rod, measured with ultrasonography, was >12.0 mm in all the cases and located deep in the muscular layer in the failure cases. The depth of the implants positively correlated with the time spent for removal (r=0.525; P=0.015).

Conclusion

High frequency ultrasonography is a highly accurate tool for localization and measurement of the skin-to-rod depth. It is also useful for removing non-palpable implants. If the depth of the implant is >12.0 mm, removal of the implant in the operating room under general anesthesia is recommended.

Influence of age on tolerability, safety and effectiveness of subdermal contraceptive implants

The use of long-acting contraceptive methods is on the rise. The aim of this study was to describe the main variables (effectiveness, tolerability, menstrual bleeding) associated with the use of subdermal contraceptive implants and to investigate the influence of age on these variables. This was a descriptive, retrospective, observational study of 221 cases of contraceptive implants inserted at a Spanish hospital between 2006 and 2015. The mean age of implant users was 31.2 ± 7.5 years. Effectiveness was 100% and good tolerability was recorded for 86.5%. Infrequent bleeding was the most common bleeding pattern, followed by amenorrhoea. Of the 221 implants inserted, 47.5% were removed. The main reasons were expiration (54.3%) and discomfort due to bleeding alterations and other adverse effects (25.7%). Nulliparity and weight gain were significantly associated with an increased probability of implant removal. This study shows that implants were highly effective, safe and well-tolerated in our population. The age of users had no influence on any of the study variables analysed. Impact Statement What is already known on this subject? Subdermal contraceptive implants are long-acting reversible contraceptives which are both safe and effective. What do the results of this study add? The age of users had no influence on any of the study variables analysed. Nulliparity and weight gain were significantly associated with an increased probability of implant removal. What are the implications of these findings for clinical practice and/or further research? Subdermal contraceptive implants were a safe and effective long-acting progestin contraceptive method for women from all age groups in our series because no significant age-related differences were observed for the tolerability, vaginal bleeding patterns, the effectiveness, the adverse effects or any other variables.

Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.

Recent advances in contraception

Focusing on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives, we review recent advances in contraceptive development and discuss progress in policies to improve access to the most effective methods. We report on the shift in practice towards routinely providing IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of the insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, we describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, which comes with a preloaded inserter. We also discuss the efficacy of ulipristal acetate versus levonorgestrel for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of the increasing interest in providing IUCs and implants to women in the immediate postpartum and post-abortion periods, we consider the rationale for this change in practice and review the progress that has been made so far in the United States.

Contraceptive procedures

Although most women desire to control the size and spacing of their family, the rate of unintended pregnancy in the United States remains high, with approximately half of all pregnancies being unintended. Reducing unintended pregnancy is a national public health goal, and the increased use of long-acting reversible contraceptives (LARCs) (intrauterine devices and implants) can help meet this goal. LARCs are among the most effective forms of contraception available. There are few contraindications to their use, and insertion and removal are straightforward procedures that are well tolerated in the outpatient office setting.

Sexual life impact evaluation of different hormonal contraceptives on the basis of their methods of administration

PURPOSE

The aim of this study is to evaluate and compare sexual satisfaction with the use of three types of hormonal contraceptives.

METHODS

We have evaluated the sexological profile of 23 patients, treated with a subdermal hormonal contraceptive containing 68 mg etonogestrel. We have compared this profile to that of other two groups of previously studied patients: one consisting of 26 women treated with a vaginal ring releasing 120 µg/day of etonogestrel and 15 µg/day of ethinylestradiol (EE) and one consisting of 25 women treated with an oral contraceptive containing 20 µg of EE and 150 µg of desogestrel. A further group of 25 women, not in treatment with any type of hormonal contraceptive, has been studied as control group. The Interviewer Rating of Sexual Function (IRSF) has been completed by the patients at the beginning of the study and after cycles of 3 and 6 months of contraceptive usage.

RESULTS

All three types of hormonal contraceptives have increased positive indicators of patients' sexual life (sexual interest and fantasies, of orgasm number and intensity and satisfaction) and decreased negative ones (anxiousness, discomfort).

CONCLUSIONS

Subdermal contraception is slower than both intravaginal and oral hormonal contraceptives in giving these effects, but is more effective after a cycle of 6 months of usage.

Progestin-only contraception: injectables and implants

Progestin-only contraceptive injectables and implants are highly effective, longer-acting contraceptive methods that can be used by most women in most circumstances. Globally, 6% of women using modern contraception use injectables and 1% use implants. Injectables are the predominant contraceptive method used in sub-Saharan Africa, and account for 43% of modern contraceptive methods used. A lower-dose, subcutaneous formulation of the most widely used injectable, depot-medroxyprogesterone acetate, has been developed. Implants have the highest effectiveness of any contraceptive method. Commodity cost, which historically limited implant availability in low-resource countries, was markedly lowered between 2012 and 2013. Changes in menstrual bleeding patterns are extremely common with both methods, and a main cause of discontinuation. Advice from normative bodies differs on progestin-only contraceptive use by breastfeeding women 0-6 weeks postpartum. Whether these methods are associated with HIV acquisition is a controversial issue, with important implications for sub-Saharan Africa, which has a disproportionate burden of both human immunodeficiency virus (HIV) and maternal mortality.

Nexplanon, a radiopaque etonogestrel implant in combination with a next-generation applicator: 3-year results of a noncomparative multicenter trial

OBJECTIVE

To investigate the efficacy, safety, removal characteristics, and x-ray visibility of Nexplanon, a radiopaque etonogestrel contraceptive implant combined with a next-generation applicator.

STUDY DESIGN

A 3-year, nocomparative, multicenter study in women aged 18-40 years at 23 clinical sites.

RESULTS

Of 301 women who had an implant inserted, none became pregnant while the implant was in situ. Serious adverse events were reported in 16 of 301 (5.3%) women; none were judged as drug related. Fibrosis around the implant was the most common removal complication (4.4%). The implant was visible on X-ray and palpable before removal with a mean removal time of 2 minutes.

CONCLUSION

Nexplanon showed high contraceptive efficacy, palpability before removal, short removal times, and few removal complications. Nexplanon provides clinicians with a long-term hormonal contraceptive method with a safety and efficacy profile comparable to Implanon, radiopacity, and a new applicator.

Bioequivalence and x-ray visibility of a radiopaque etonogestrel implant versus a non-radiopaque implant: a 3-year, randomized, double-blind study

BACKGROUND

The etonogestrel (ENG)-releasing implant is a subdermal progestogen-only contraceptive that provides coverage for up to 3 years. This long-acting hormonal contraceptive has been available in Europe since 1998 and in the US since 2006. To date, localization of non-palpable implants at insertion and before removal has been dependent on ultrasound or magnetic resonance imaging by an experienced clinician. To facilitate localization in rare cases of non-palpable implants using widely available equipment without the need for a specialist, a radiopaque ENG implant has been developed that is detectable by two-dimensional x-ray imaging.

OBJECTIVE

This study aimed to establish whether the radiopaque ENG implant is bioequivalent in situ compared with the original non-radiopaque ENG implant, and to assess x-ray visibility of the radiopaque ENG implant.

METHODS

This was a 3-year, randomized, double-blind, parallel-group study carried out in nine international clinical trial centres. Women aged 18-40 years at the time of screening, with menstrual cycles of a usual length of 24-35 days and a body mass index of between ≥18 and ≤29 kg/m(2) were included. Women were assigned to either the radiopaque or non-radiopaque ENG implant in a 1 : 1 ratio via a block randomization by centre. Bioequivalence testing was performed based on the peak ENG concentration (C(max)), and the area under the curve (AUC) for ENG at 6, 24 and 36 months (AUC(6 mo), AUC(24 mo) and AUC(36 mo)) after insertion. For this purpose, blood sampling for pharmacokinetic determination was performed prior to insertion and for up to 3 years afterwards. Bioequivalence was defined as the 90% confidence interval (CI) of the ratio radiopaque implant/non-radiopaque implant of the geometric means (GMR) within the acceptance range of 0.80-1.25. x-Ray visibility was assessed by two-dimensional x-ray imaging after insertion and before removal of the implant.

RESULTS

The pharmacokinetic profiles of ENG indicated that the radiopaque and non-radiopaque implants were bioequivalent with respect to the geometric mean of C(max) (GMR 1.06; 90% CI 0.91, 1.23), AUC(6 mo) (GMR 1.00; 90% CI 0.91, 1.10), AUC(24 mo) (GMR 0.98; 90% CI 0.88, 1.10) and AUC(36 mo) (GMR 1.00; 90% CI 0.89, 1.11). The radiopaque ENG implant was clearly visible in 50 out of 52 women after insertion and in all 52 women before removal, whereas none of the non-radiopaque implants were visible.

CONCLUSION

The radiopaque ENG implant is bioequivalent in situ compared with the original non-radiopaque ENG implant and is clearly visible using x-ray imaging.

CLINICAL TRIALS REGISTRATION

Registered as ClinicalTrials.gov identifier NCT00620464.

A risk management approach to the design of contraceptive implants

This article assesses the risks associated with the insertion and removal of contraceptive implants. Risks to patient safety relate to the way the insertion device is designed and used, rather than to the pharmacological properties of the implant itself. Risks associated with removal are not amenable to thoughtful design. A systems approach is taken, the assumption being that human errors are symptoms of underlying systems deficiencies rather than causes of adverse events. The insertion procedure is broken down into five key steps. Errors in these steps contribute to non-insertion and deep insertion of implants. The design of the Implanon(®) applicator is critically examined and suggestions made as to how it could be improved in such a way as to reduce errors in its use. The exercise undertaken has coincided with the imminent launch of the redesigned applicator of the new contraceptive implant, Nexplanon(®). Preliminary comments are made about the new features of Nexplanon.