Real world data on Nexplanon® procedure-related events: final results from the Nexplanon Observational Risk Assessment study (NORA)

Migration of etonogestrel subcutaneous contraceptive implants: systematic review and recommendations for practice

INTRODUCTION

Migration is a rare but serious complication of the etonogestrel contraceptive implant, and little is known about its extent.

PURPOSE

To document and characterise cases of etonogestrel contraceptive implant migration in the scientific literature.

METHODS

A systematic review of Medline, Embase and Global Health databases was carried out between January 2000 and January 2023 to identify articles presenting implant migrations. Narrative reviews, conference abstracts and articles not written in English or French were excluded.

RESULTS

Forty-five articles, mostly published since 2016, were identified (eight case series and 37 case reports), for a total of 148 independent cases of migration: in pulmonary blood vessels (n = 74), in non-pulmonary blood vessels (n = 16) and extravascular (n = 58). Many patients are asymptomatic and migration is often an incidental finding. A non-palpable implant and symptoms related to implant location (intra- or extra-vascular) may be indicative of migration. Inadequate insertion and normal or underweight appear to increase the risk of migration. Scientific societies and authors offer practical strategies to deal with implant migration.

CONCLUSION

Professionals who insert and remove contraceptive implants must be adequately trained. They need to be on the lookout for implant migration, and promptly refer patients to appropriate care if migration is suspected.

A retrospective analysis of factors associated with deep contraceptive implant removals compared to superficial removals

OBJECTIVE

To identify factors associated with the need for a deep etonogestrel contraceptive implant removal as compared to superficial removal.

STUDY DESIGN

We conducted a retrospective cohort study of patients undergoing contraceptive implant removal from January 2014 to January 2023. We extracted key patient characteristics from electronic health record review and compared patients requiring deep removal versus routine superficial removal using Chi-squared, Fischer's exact, and Mann-Whitney U test. A multivariate logistic regression identified variables associated with increased odds of requiring a deep implant removal.

RESULTS

The deep and superficial removal groups included 162 and 585 patients, respectively. Deep removal was associated with younger age at removal (median 25.0 vs 26.0 years, p = 0.005), lower body mass index (BMI) at insertion (median 23.2 kg/m2 vs 26.6 kg/m2, p = 0.024), BMI≥ 40 kg/m2 at removal (15.2% vs 7.0%, p = 0.007), weight gain during implant use (median 6.6 vs 1.8 kg, p ≤ 0.001), longer duration of use (median 36.0 vs 27.5 months, p < 0.001), implant exchange (37.3% vs 17.4%, p < 0.001), and insertion by non-physician (43.3% vs 19.3%, p < 0.001) or non-obstetrican and gynecologist (31.4% vs 11.8%, p < 0.001). Lower BMI at insertion (aOR 0.92, [95% CI 0.87-0.98]), weight gain during use (aOR 1.06 [95% CI 1.02-1.10]), and longer duration of use (aOR 1.05 [95% CI 1.02-1.07]) remained significantly associated with deep removal in regression analysis.

CONCLUSION(S)

We identified lower BMI at insertion, weight gain during use, and longer duration of use as independent factors associated with increased likelihood of needing a deep contraceptive implant removal.

IMPLICATIONS

Clinicians should utilize proper technique when inserting contraceptive implants, especially in patients at risk for deep insertion, and ensure immediate referral to Centers of Experience for patients with non-palpable implants.

Etonogestrel-releasing subdermal contraceptive implant: Budget impact analysis based on the Brazilian private healthcare system

High rates of unplanned pregnancies persist despite pharmacological developments and advancements in contraceptive methods. Here, we demonstrate that the etonogestrel-releasing subdermal contraceptive implant (IMP-ETN) may be an appropriate and cost-effective alternative to levonorgestrel-releasing intrauterine systems (LNG-IUSs) for women in Brazil. For our pharmacoeconomic analysis, we reviewed the literature on IMP-ETN regarding its acceptance, eligibility criteria, choice, relations with age, adverse events and, finally, the unmet need in the fee-for-service private healthcare sector. We considered qualitative observations in combination with quantitative analysis and performed a deterministic sensitivity analysis to investigate whether this technology can be self-sustainable over a period of five years. The target population for this analysis comprised 158,696 women. Compared with the continued use of LNG-IUSs, adopting the IMP-ETN can result in a cost avoidance of $ 7.640.804,02 in the first year and $ 82,455,254.43 in five years. Disseminating information among physicians will promote this change and strengthen the potential cost avoided by private health system payers. These savings can be used to improve other healthcare programs and strategies. Moreover, the principles of care can be promoted by improving and adapting healthcare systems and expanding treatment and follow-up strategies. This would also provide support to women's reproductive rights and improve their quality of life. Our results suggest that the IMP-ETN has a favorable cost-effectiveness profile. Given all its advantages and negative incremental cost impact over a period of five years, the IMP-ETN may be a more favorable alternative to LNG-IUSs. Therefore, it should be offered to beneficiaries with a private healthcare plan. This analysis overcomes previous barriers to the use of cost-benefit models, and our results may help balance decision-making by policymakers, technical consultants, and researchers.

Localization and removal of nonpalpable contraceptive implants: Experience from a teaching hospital in Ethiopia: A case series

OBJECTIVE

To assess the outcome of women presenting with nonpalpable contraceptive implants to a referral center in Ethiopia. In addition, we discuss our approach and experience with localization and removal of nonpalpable contraceptive implants.

METHODS

We conducted a facility-based retrospective review of patients evaluated for a nonpalpable contraceptive implant between September 2019 and March 2022 at St. Paul's Hospital Millennium Medical College (SPHMMC) located in Addis Ababa, Ethiopia. SPHMMC is a tertiary teaching hospital with Obstetrics and Gynecology (OBGYN) residency as well as a Family Planning fellowship program. The present study was approved by the institutional review board of SPHMMC.

RESULTS

Of the 68 patients reviewed, 48 were referred from other facilities. A total of 24 (35.3%) patients had at least one previous failed attempt at removal before referral. On ultrasound examination, 27 (40.3%) implants were found below the muscle fascia. Implant removal procedures were successfully done at the outpatient clinic in 65 (95.6%) patients including 40/40 (100%) suprafascial and 25/27 (92.6%) subfascial implants. Removal of subfascial implants was performed in the operating room in two patients. We failed to localize the device in one patient currently on follow-up. All removals were performed by OBGYNs with subspecialty training in family planning or current fellows supervised by subspecialists. No post-procedure complications have been documented.

CONCLUSION

Our findings show that with meticulous evaluation and careful patient selection, localization and removal of nonpalpable implants in outpatient settings are successful. Initial ultrasonography minimizes delays and allows for same-day implant localization and removal.

Reversible female contraceptives: historical, current, and future perspectives†

Contraception is a practice with extensive and complicated social and scientific histories. From cycle tracking, to the very first prescription contraceptive pill, to now having over-the-counter contraceptives on demand, family planning is an aspect of healthcare that has undergone and will continue to undergo several transformations through time. This review provides a comprehensive overview of current reversible hormonal and non-hormonal birth control methods as well as their mechanism of action, safety, and effectiveness specifically for individuals who can become pregnant. Additionally, we discuss the latest Food and Drug Administration (FDA)-approved hormonal method containing estetrol and drospirenone that has not yet been used worldwide as well as the first FDA-approved hormonal over-the-counter progestin-only pills. We also review available data on novel hormonal delivery through microchip, microneedle, and the latest FDA-approved non-hormonal methods such as vaginal pH regulators. Finally, this review will assist in advancing female contraceptive method development by underlining constructive directions for future pursuits. Information was gathered from the NCBI and Google Scholars databases using English and included publications from 1900 to present. Search terms included contraceptive names as well as efficacy, safety, and mechanism of action. In summary, we suggest that investigators consider the side effects and acceptability together with the efficacy of contraceptive candidate towards their development.

Long-Acting Reversible Etonogestrel Subdermal Implant in Adolescents

Several effective contraceptive options are available for use by adolescents, including the long-acting reversible subdermal implant and intrauterine devices, which provide a high level of convenience, privacy, and effectiveness for an adolescent. Knowledge of all the effective birth control methods is essential for the pediatrician to be able to provide effective contraceptive counseling for an adolescent. An approach to counseling using a reproductive justice framework, which allows the provider and adolescent patient to engage in shared decision-making, is described. This article focuses on the long-acting reversible etonogestrel (ENG) subdermal implant for adolescents. The ENG implant is labeled for preventing pregnancy by suppressing ovulation. The ENG implant may also have a role in ameliorating dysmenorrhea and heavy menstrual bleeding. Postlabeling studies indicate that the ENG implant is effective for up to 5 years, although the device's labeling states effectivenessup to 3 years. The main contraindication to using the ENG implant is pregnancy itself. Safe initiation of the ENG implant is described, including an approach to determine whether an adolescent is pregnant. The main adverse effect of the ENG implant is an unpredictable bleeding pattern that is most often ameliorated by use of nonsteroidal anti-inflammatory medications, as well as estrogen, if not contraindicated for the patient. Details of the insertion and removal procedures, including potential complications, are described to enable the pediatrician to provide effective anticipatory guidance for the adolescent.

Pregnancy and pregnancy outcomes in a prospective cohort study: Final results from the Nexplanon Observational Risk Assessment Study (NORA)

OBJECTIVES

To monitor pregnancy occurrence and outcomes among Nexplanon users in the United States during standard clinical practice.

STUDY DESIGN

The Nexplanon Observational Risk Assessment (NORA) study was a large prospective cohort study conducted in the United States (US). Study participants with a newly inserted Nexplanon implant were recruited by health care professionals (HCPs) who had completed the Nexplanon clinical training. Via a survey, study participants were followed up at 6-month intervals for 36 months and 6 months after implant removal. Reported unintended pregnancies were validated and classified as noninsertion, preinsertion, during-use, or postremoval.

RESULTS

Four hundred and twenty-eight HCPs in 47 states recruited 7364 Nexplanon users. Pregnancies included one noninsertion, eight preinsertion, three during-use, and 14 postremoval pregnancies; of these 26 pregnancies, 22 resulted in the birth of a healthy child, two resulted in an induced abortion, one resulted in a spontaneous abortion, and one resulted in an ectopic pregnancy. Six pregnancies occurred during-use (n = 3) or within 7 days following implant removal (n = 3), yielding a Pearl Index of 0.04 (95% CI, 0.02-0.09).

CONCLUSIONS

Nexplanon is an effective contraceptive in real-world users; the Pearl Index was 0.02 (95% CI, 0.00-0.06) for during-use pregnancies, and 0.04 when including pregnancies that occurred within 7 days following implant removal.

IMPLICATIONS

This large real-world-use study indicates that Nexplanon is as effective as shown in the preapproval clinical trials.

Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal

Introduction

Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges.

Methods

We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals.

Results

72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals.

Conclusion

Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

Infective Endocarditis in Hypertrophic Obstructive Cardiomyopathy After Etonogestrel Implant Removal

The modified Duke criterion "predisposing heart condition" is poorly defined, and is based on outdated studies of the epidemiology of infective endocarditis (IE). Hypertrophic obstructive cardiomyopathy (HOCM) is not classified as a modified Duke criterion for the diagnosis of IE but is associated with a higher incidence of IE nonetheless. The presence of a cardiovascular implantable electronic device (CIED) is independently associated with an increased risk of IE. Patients with HOCM may be candidates for the implantation of an automated internal cardiac defibrillator (AICD) for the prevention of sudden cardiac death. Previous studies of the risk of IE in patients with HOCM did not make a distinction for patients with CIEDs. We present a case of a 25-year-old female with HOCM and an AICD for primary prevention, who presented with sudden right-sided hemiplegia, aphasia, dysarthria, and a low-grade fever. CT angiography demonstrated large vessel occlusion of the terminal left internal carotid artery and proximal middle cerebral artery (MCA), prompting emergent treatment with mechanical thrombectomy, which achieved full recanalization and full reperfusion. Cardioembolic stroke was suspected. She had no arrhythmias, a transthoracic echocardiogram showed new mitral valve vegetation. The etiology of the stroke was determined to be septic emboli from mitral valve subacute bacterial endocarditis and two blood cultures grew staph epidermidis. Ten days prior to presentation, she had undergone removal of an etonogestrel implant in her arm, and this was the suspected source of initial bacteremia and valvular seeding. She was treated with a six-week course of vancomycin with improvement and maintained on daily minocycline as long as the AICD were to remain in place. Our patient started developing symptoms of endocarditis after the removal of her etonogestrel implant, had no other recent procedures, and had good dentition. Hence, we maintain that this was the likely source of her initial bacteremia that led to valvular seeding and resultant IE. This is the first reported case of etonogestrel implant removal-related endocarditis. Further studies of the association between etonogestrel implant removal, transient bacteremia, and valvular seeding leading to IE are warranted. Clinicians should be reminded of the increased risk of IE in patients with HOCM. Identifying HOCM patients at higher risk for IE, i.e. dilated left atrium and/or CIEDs is easier to accomplish with current cardiac imaging techniques.

Characteristics of Patients Requiring Surgical Removal of Subdermal Contraceptive Implants: A Case-Control Study

Purpose

Etonogestrel subdermal implants are a commonly used contraceptive device placed in the medial upper arm. Plastic and orthopedic surgeons may be consulted for difficult implant removals. We performed a case–control study comparing patients undergoing surgical and uncomplicated in-office removal at our institution.

Patients and Methods

We identified patients who underwent operative removal of implantable contraceptive devices by plastic or orthopedic surgeons at our institution from January 2014 to October 2019. Patients who underwent uncomplicated office removal during the same time were compared. Demographic and surgical variables were collected, and descriptive statistics were calculated. Univariate and multivariate logistic regression was performed with surgical versus outpatient removal as the outcome of interest.

Results

A total of 669 patients undergoing etonogestrel subdermal implant removals were identified during the five-year study period, of which thirteen patients required surgical removal (1.9%) and 326 were selected as uncomplicated removal comparisons. There were no significant differences in median (IQR) body mass index (BMI) (31.1 [28.2, 35.2] versus 29.3 [24.0, 35.1], p = 0.19), median (IQR) weight gain since device placement (5 [−0.6, 14.7] kilograms versus 1.6 [−1.2, 5.8] kilograms, p = 0.15), or length of time since device insertion (2.3 [0.8, 2.8] years versus 1.0 [0.4, 2.2] years, p = 0.17). Of those who needed surgical removal, the most common indication for implant removal was device expiration (n = 5, 38.5%). Devices placed by OBGYN attendings were less likely to require surgical removal (p = 0.02). Family medicine attendings were more likely to refer patients for surgical removal (p = 0.02). No significant findings were detected on univariate or multivariate regression. Among surgical removals, radiography was the most frequently used imaging modality. Implants were most frequently subdermal (n = 11, 84.6%) though intramuscular placement was also identified (n = 2, 15.4%). Only one patient had residual paresthesia along the length of the incision. No other complications were identified.

Conclusion

We did not identify risk factors associated with the difficult removal of etonogestrel subdermal implants. Practitioners should consult upper extremity surgeons if they encounter difficult removals.

Management of etonogestrel implant migration into the pulmonary artery

OBJECTIVES

To evaluate the relationship between time since contraceptive implant placement and retrieval outcomes in patients with implant migration into the pulmonary artery.

STUDY DESIGN

We reviewed all cases of pulmonary artery implant migration referred to the Marie Lannelongue hospital from 2015 through 2020. Using our hospital database, we collected patients' clinical data and removal information to assess the success of therapeutic management according to the delay between implant insertion and removal.

RESULTS

We identified eight cases. Physicians located two in the upper and six in the lower lobe. Five patients had associated pulmonary symptoms, most commonly, chest pain and dyspnea. Physicians attempted an endovascular procedure in all cases with successful removal in three patients. In the five failures, angiography displayed arterial thrombosis distal to the implant. These patients had successful removal with an open mini-thoracotomy (<5 cm). None of the eight patients had serious post-operative complications.  For the three patients with successful endovascular retrieval, two had early diagnosis (≤ 3 months).

CONCLUSION

Endovascular approach with angiography should be performed as a first line treatment modality. Endothelialization and fibrosis within the vessel represent the principal limitations of endovascular strategy, but a retrieval could be attempted anyway with caution. In case of failure, an open approach is required.

IMPLICATIONS STATEMENT

When a migration into the pulmonary artery is diagnosed, health care professionals should refer patients as soon as possible to a tertiary center with a vascular surgery/interventional radiology and thoracic surgery departments.

Experiences of Accessing and Providing Contraceptive Implant Removal Services in Gaborone, Botswana: A Qualitative Study Among Implant Users and Healthcare Providers

Introduction: This study explored implant user and healthcare provider experiences of accessing and providing contraceptive implant removal services in Gaborone, Botswana, following introduction of the implant in the public sector in 2016. We sought to understand reasons for satisfaction and dissatisfaction with services and their potential impact on wider perceptions of the implant, including influence on future uptake.

Methods: Qualitative data were collected through in-depth interviews. Participants comprised ten women who had previously undergone implant removal, and ten providers whose work included provision of implant insertion and removal. Data were analyzed using thematic content analysis.

Results: Seven of the ten users in this study had experienced a delay between initial request and undergoing implant removal. This interval ranged from <1 week to 3 months. Users identified the principal barriers to accessing implant removal services as lack of access to trained removal providers, inconvenient appointment times, and provider resistance to performing removal. Nine of the ten providers in this study had experienced barriers to providing implant removal, including insufficient training, lack of equipment, lack of time, and lack of a referral pathway for difficult removals. Despite experiencing barriers in accessing removal, users' perceptions of the implant remained generally positive. Providers were concerned that ongoing negative user experiences of removal services would damage wider perceptions of the implant.

Conclusion: Introduction of the contraceptive implant in Botswana has been an important strategy in increasing contraceptive choice. Following an initial focus on provision of insertion services, the development of comparable, accessible removal services is critical to ensuring that the implant remains a desirable contraceptive option and is vital to upholding women's reproductive health rights. The experiences of users and providers in this study can inform the ongoing development of services for implant insertion and removal in Botswana and other lower-resource settings.

Contraceptive Technology: Present and Future

Many sexually active, reproductive-aged persons capable of becoming pregnant use some method of contraception. To expand options for those desiring birth control, new choices include a vaginal ring, transdermal patch, progestin-only pill, and spermicide. Compared with currently available methods, additional technologies that are highly effective, easy to use, cost efficient, and well-tolerated lay on the horizon. During contraceptive counseling, patient choice, and reproductive autonomy should remain paramount.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe

Objectives

The aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance.

Methods

The ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included.

Results

All implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction).

Conclusions

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication.

Key Points

• Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm).

• The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain.

• This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08263-4.

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.

Real-world cost-effectiveness of etonogestrel implants compared to long-term and short term reversible contraceptive methods in France

BACKGROUND

To estimate the cost-effectiveness (CE) of etonogestrel implants compared to other long-term and short-term reversible contraceptive methods available in France.

RESEARCH DESIGN AND METHODS

A 6-year Markov model compared effectiveness between the implant and six other contraceptive methods in sexually active, not-pregnancy-seeking French females of reproductive age. Contraception efficacy, switch rates and outcomes were based on French current medical practice. Incremental CE ratios (ICERs) were calculated as incremental cost per unintended pregnancy (UP) avoided. Efficiency frontier was plotted to identify cost-effective methods. Uncertainty was explored through sensitivity analyses.

RESULTS

The implant was on the efficiency frontier along with combined oral contraceptive pill (COC) and copper IUD. Implant avoids between 0.75% and 3.53% additional UP per person-year compared to copper IUD and second generation COC, respectively, with an ICER of €2,221 per UP avoided compared to copper IUD. For the 240,000 French women currently using the implant, up to 8,475 UPs and up to 1,992 abortions may be prevented annually.

CONCLUSION

With more unintended pregnancies avoided and comparable costs to copper IUD, the implant is a cost-effective option among long-term and short-term reversible contraceptive methods.

Subfascial-located contraceptive devices requiring surgical removal

Background

Subdermal etonogestrel implants are highly effective contraceptive methods. Despite standardization of insertion technique by the manufacturer, some implants are inadvertently placed too deeply within or below the plane of the biceps brachii fascia. Placement of these implants in a deep tissue plane results in more difficult removal, which is not always possible in the office setting. In rare cases, surgical removal by an upper extremity surgeon is warranted.

Case presentation

Here we present 6 cases of etonogestrel implants located in a subfascial plane requiring removal by an upper extremity surgeon. Implants were all localized with plain radiography and ultrasound prior to surgical removal. All cases had implants located in the subfascial plane and one was identified intramuscularly. The average age was 28 years (19–33) and BMI was 24.0 kg/m^2 (19.1–36.5), with the most common reason for removal being irregular bleeding. The majority of cases (5/6) were performed under monitored anesthesia care with local anesthetic and one case utilized regional anesthesia. All implants were surgically removed without complication.

Conclusions

Insertion of etonogestrel contraceptive implants deep to the biceps brachii fascia is a rare, but dangerous complication. Removal of these implants is not always successful in the office setting and referral to an upper extremity surgeon is necessary to avoid damage to delicate neurovascular structures for safe removal.

US referral center experience removing nonpalpable and difficult contraceptive implants with in-office ultrasonography: A case series

OBJECTIVES

To assess referral center outcomes with removal of difficult or nonpalpable contraceptive implants using high-frequency point-of-care ultrasonography.

STUDY DESIGN

We present a case series examining patients referred to our specialty center from January 2019 through September 2020 for difficult or nonpalpable implant removal.

RESULTS

Of the 54 referrals, 6 had palpable implants and 48 required ultrasonography. We localized 46 (96%) implants in-office, including 13 located subfascially; 2 Implanon implants could not be localized. We successfully completed 50 (96%) of 52 attempted in-office removals, including 12 (92%) subfascial implants.

CONCLUSION

High-frequency point-of-care ultrasonography can effectively localize nonpalpable contraceptive implants leading to successful in-office removal.

IMPLICATIONS

Specialists can use high-frequency point-of-care ultrasonography to localize nonpalpable implants without formal radiology scans and skilled technologists, optimizing patient time and convenience. However, the probe is expensive, and providers may need to consider this cost in the context of reimbursement for these highly specialized procedures.

Quality of life of women using the etonogestrel long-acting reversible contraceptive implant after abortion for unplanned pregnancy

OBJECTIVES

The aims of the study were to investigate the effect of a subcutaneous etonogestrel-containing contraceptive implant on the quality of life (QoL) and sexual function of women who had undergone termination of an unplanned pregnancy.

METHODS

At pregnancy termination 140 women received contraceptive counselling on the etonogestrel implant. The Short Form-36 questionnaire, the Female Sexual Function Index and the Female Sexual Distress Scale were used to investigate, respectively, the QoL, sexual function and sexual distress of the women at baseline and at 6, 12, 24 and 36 months of follow-up.

RESULTS

The study group comprised 86 (61.4%) women who chose to use the contraceptive implant. The control group comprised 28 (20.0%) women who chose to use short-acting reversible contraception (SARC) and 26 (18.6%) women who chose not to use hormonal contraception. In the women not using hormonal contraception there were 23 (88.5%) unintended pregnancies before the end of the 3 year study period. QoL, sexual function and sexual distress improved in the study group from the 6 months follow-up until the end of the study (p < 0.001). QoL (p < 0.02) and sexuality (p < 0.001) gradually improved in the control group after 24 and 12 months of follow-up, respectively. None of the women using the etonogestrel implant became pregnant during the study. Inter-group analysis showed better improvement in QoL, sexual function and sexual distress in the study group than in the control group from 6 months (p < 0.004) until the end of the study (p < 0.001).

CONCLUSION

Compared with SARC and non-hormonal contraception, the contraceptive implant promoted better QoL and sexuality in users and reduced the incidence of unplanned pregnancy. However, the women who opted for SARC or non-hormonal contraception did so because of the lower cost compared with that of the contraceptive implant.

Incidence and characteristics of intravascular pulmonary migration of etonogestrel implants: A French nationwide study

OBJECTIVE(S)

To describe the features of etonogestrel implant (Nexplanon and Implanon) migration into the pulmonary vasculature and to estimate its incidence in France.

STUDY DESIGN

We retrospectively reviewed French cases of implant migration into the pulmonary vasculature reported up to 2018. Patient clinical data were collected. The annual incidence of migration was estimated from the number of cases reported and number of implants sold.

RESULTS

Twenty-seven cases of migration into the pulmonary vasculature were identified. In 19 cases (70%) it was stated that this was into the pulmonary artery (nine into the left branch, four into the right branch and six unspecified) and in the other eight cases (30%) it was it not specified whether this was into the pulmonary artery or one of its branches. The migration was discovered following a request for implant removal in 59% of cases, following respiratory complaints in 24%, and because the implant was no longer palpable in 17%. In the 24 cases for which information on removal (or not) was available, the implant was removed in 15 (60% by an endovascular procedure and 40% by invasive surgery); in the remainder it was left in situ. The incidence of migration into the pulmonary vasculature was 1.23 per 100,000 implants sold [95% CI 0.25-3.58] in 2014, increasing to 3.17 per 100,000 implants sold [1.37-6.24] in 2017. In 2016, the French National Agency for Medicines and Health Products Safety (ANSM) had recommended performing a systematic search for non-palpable implants, including at thorax level.

CONCLUSIONS

The incidence of migration into the pulmonary vasculature is low. Nonetheless, because the consequences are potentially serious, in December 2019 the ANSM made recommendations to reduce this risk.

Difficult etonogestrel implant removals in South Africa: A review of 74 referred cases

OBJECTIVES

To assess etonogestrel contraceptive implant location and outcomes among women referred for "difficult" removal to a specialist clinic in South Africa.

STUDY DESIGN

We performed a retrospective review of cases referred to our clinic for removal of nonpalpable, deep, migrated, or damaged implants, or failed removals from March to August 2017.

RESULTS

Most (n = 68, 92%) of the 74 referrals were nonpalpable in our clinic. We used ultrasound for localization and successfully removed 72 implants (97%) in the outpatient clinic.

CONCLUSION

With proper protocols and equipment, localization and removal of nonpalpable implants can be safely and effectively achieved in an outpatient African setting.

IMPLICATIONS

Access to providers specially trained in ultrasound localization should be available in all settings where implants are offered. Providing timely access to safe and effective implant removals in routine and difficult cases is essential to ensuring that implant programs are in alignment with rights-based, client-centered family planning principles.

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.