Methods of accurate localisation of non-palpable subdermal contraceptive implants

Successful Removal of Six Levonorgestrel Silastic Subcutaneous Implants (Norplant) 25 Years After Insertion: A Case Report

Levonorgestrel-releasing silastic implants are a form of subdermal contraception that utilizes implanted silastic rods to release levonorgestrel, providing long-acting reversible contraception over an extended period of time. This case report presents a female who had lost a significant amount of weight after receiving levonorgestrel-releasing implants 25 years prior. During the elapsed period, the rods were palpable and uncomfortable. She had previously been unable to find a provider willing to remove the implants. This case highlights the possible complications surrounding the removal of levonorgestrel silastic subcutaneous implants and the careful consideration required when the implant has been in place for an extended period.

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.

Pre-Clinical Evaluation of a Task-Shifting Contraceptive Implant Insertion Device for Use in Low- and Middle-Income Countries

Worldwide, 225 million women have unmet contraceptive needs which, every year, leads to 52 million unintended pregnancies. A challenge to providing universal access to contraception is the large proportion of the population living in rural, difficult to access settings in low- and middle-income countries. The availability and delivery of effective contraception in rural areas is limited by the lack of trained healthcare providers. Barriers to the use of long-acting contraceptives in rural areas are more pronounced due to the advanced skill and training to administer. In this study, we describe the design and testing of the SubQ Assist, a task-shifting contraceptive implant insertion device that aims to reduce the training requirements for administering contraceptive implants while simultaneously ensuring safe and high quality administration. Cadaver testing in conjunction with ultrasound depth measurements were used to evaluate the efficacy of the SubQ Assist. Implant insertion between the SubQ Assist and a trained physician are compared. Cadaver testing and ultrasound depth measurements demonstrate that the SubQ Assist results in implant insertions that are statistically equivalent to implants inserted by a trained physician. Additionally, the results show that the lateral positioning of these implants would facilitate uncomplicated removal at a later date. These findings demonstrate proof of concept for the SubQ Assist and provide evidence for moving towards clinical testing. They demonstrate that the SubQ Assist may be an effective method of task-shifting the insertion of contraceptive implants to minimally trained providers in order to expand access in rural areas.

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.

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.

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

OBJECTIVES

We aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care.

STUDY DESIGN

We reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach.

RESULTS

Two patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety.

CONCLUSION

When necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

Removal of a Nexplanon implant located in the biceps muscle using a combination of ultrasound and fluoroscopy guidance

Despite modifications to avoid deep insertions, clinical experience with Nexplanon demonstrates that deep insertions still occur. We present a case of a Nexplanon found in the biceps muscle that was successfully removed with a small incision using a combination of ultrasound and fluoroscopy guidance by interventional radiologists.

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.

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.

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

BACKGROUND

The etonogestrel (ENG) implant Implanon is a progestin-only contraceptive that provides effective contraception for up to 3 years. A new radiopaque ENG implant has been developed to extend the diagnostic modalities of Implanon and a next-generation applicator (NGA) was designed to facilitate correct subdermal insertion of Implanon.

STUDY DESIGN

In this open-label study, 23 investigators, experienced and inexperienced with Implanon, performed 301 insertions of the new radiopaque implant using the NGA. Primary outcome measurements were obtained from clinician satisfaction questionnaires completed after the 4th, 8th and 12th insertions. Additionally, insertion characteristics and X-ray visibility were assessed.

RESULTS

Almost all investigators were satisfied with the NGA from the first insertion onward, and all were satisfied or very satisfied after 12 insertions. The most frequently reported advantages included ease of use, one-handed action and fast insertion time; 2% of insertions were considered difficult in skin puncturing and/or sliding the needle subdermally. Three incorrect insertions occurred due to noncompliance with instructions. All assessed implants were visible on plain X-ray imaging.

CONCLUSIONS

The NGA was well accepted by investigators with or without prior experience with Implanon. The results stressed the importance of correctly following implant insertion instructions.