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I totally agree with all the comments made by Drs Searle, O'Brien and Rowlands in their excellent, detailed letter.1 I agree that Nexplanon® has not solved the problem of impalpable implants that are due to more deeply inserted implants. I visit the centres that deal with such cases, and the doctors working there confirm that they are seeing just as many cases. Despite the teaching programme there are too many impalpable implants. I disagree with the proposed procedure outlined …

This case highlights a rare but potentially life-threatening complication of a contraceptive implant insertion that was corrected by a noninvasive endovascular procedure. This procedure requires a quick intervention to be successful.

OBJECTIVE: To evaluate initiation of a two-rod 150-mg levonorgestrel contraceptive implant on womens perceived and observed body weight. METHODS: We conducted a secondary analysis of data from an open randomized controlled trial of adult nonpregnant human immunodeficiency virus-negative women attending a public clinic in Kingston Jamaica who were assigned to initiate implant use either immediately or after a 3-month delay. The primary objective of the parent study was to assess the effect of initiation of the implant on the frequency of condom use. We compared study arms during follow-up using one-sided chi tests for differences in perceived weight gain and loss one-sided Wilcoxon-Mann-Whitney tests for median gain in measured weight and logistic regression with generalized estimating equations for risk of gaining greater than 2 kg. RESULTS: From 2012 to 2014 women were assigned to the implant (n=208) or delay arm (n=206). At 3 months more women in the implant arm (15.3%) reported perceived weight gain than in the control arm (4.3%) (P=.01). Despite differences in perception the implant and control arms did not differ significantly in median weight gain at 1-month (0.0 kg and 0.0 kg respectively; P=.44) and 3-month visits (0.5 kg and 0.0 kg respectively; P=.27). Study arms did not differ in risk of gaining greater than 2 kg (odds ratio 0.9 95% confidence interval 0.6-1.3). CONCLUSION: We found no evidence of weight gain from short-term implant use. Through the power of the nocebo effect the practice of counseling women to expect possible weight gain from initiating implant use could lead them to perceive weight gain even in its absence and contribute to the early discontinuation of this highly effective contraceptive method.

Objectives To evaluate whether home visits for contraceptive implant insertion result in an increase in postpartum uptake compared to clinic insertion and to assess the feasibility of home insertions. Study Design We randomized women within 10 weeks of a birth or dilation and curettage (D&C) for abortion or miscarriage to home or standard office insertion. The primary outcome was successful insertion of the implant. To achieve 80% power to detect a 40% difference in visit attendance, 20 women were assigned to each group. The secondary outcome was attendance of the 4-week postpartum visit. Results From June 2013 through February 2014, we screened 45 women and 40 were randomly assigned to home and office insertion visits. We enrolled 37 postpartum women and 3 women post-D&C. Because of the significant under enrollment of the latter, we chose to report results of only the postpartum women. The results were similar whether we included or excluded post-abortion women. A majority of women desired a home visit for their implant insertion appointment at time of enrollment. Postpartum appointment attendance rates were similar between home and office visits at 53% and 50% (p=1.00), respectively. Home visits resulted in a trend toward increased implant uptake [12/19 (63%) vs 6/18 (33%), p=.10]. Conclusion Home insertion of the contraceptive implant may be a feasible option. Future studies that examine the feasibility and uptake in both postpartum and post-D&C women are warranted. Implications Women reported preference for home insertion visits in this pilot study. We also showed that a greater proportion of women received the etonogestrel implant at a home visit compared to the current standard of care, which may warrant larger studies that would have sufficient power to evaluate smaller differences.

The use of progestogen-only contraceptives may cause a change in bleeding pattern, which is a common cause of discontinuation of these methods. Co-administration with some antiretroviral therapies (ART) changes the bioavailability of the etonogestrel (ENG)-releasing contraceptive implant, possibly affecting the bleeding pattern. Bleeding patterns were evaluated in HIV-positive users of the ENG implant co-administered with two common ART regimens.Forty-five HIV-positive women who wished to use an ENG implant were included in this study: 15 had received zidovudine/lamivudine (AZT/3TC) + lopinavir/ritonavir (LPV/r) for ≥3 months (LPV/r-based ART group), 15 had received AZT/3TC + efavirenz (EFV) for ≥3 months (EFV-based ART group), and 15 had not received ART (non-ART group). Bleeding patterns were evaluated at 3 and 6 months after implant placement using a standard bleeding calendar.Amenorrhoea and infrequent bleeding rates were higher in the LPV/r-based ART group (50% and 36%, respectively) than in the other groups (non-ART group, 36% and 29%, respectively; EFV-based ART group, 7% and 14.5%, respectively; p = 0.01). The EFV-based ART group more frequently had regular bleeding (71.5%) compared with the other groups (LPV/r-based ART group, 7%; non-ART group, 21%; p = 0.01). The proportions of women with frequent and prolonged bleeding were similar (p 0.05) in the three groups.The co-administration of EFV-based or LPV/r-based ART with the ENG implant affected the expected bleeding patterns during use of the implant, although unfavourable bleeding (frequent and prolonged) was not associated with the medications under evaluation.

STUDY QUESTION Is it possible to extend the use of the 3-year one-rod etonogestrel (ENG)-releasing subdermal contraceptive implant to 5 years? SUMMARY ANSWER The extended use of the one-rod ENG-releasing subdermal contraceptive implant showed 100% efficacy in years 4 and 5. WHAT IS KNOWN ALREADY The initial regulated trials on the ENG-releasing subdermal contraceptive implant conducted in the 1990 s were designed to measure cumulative 3-year efficacy. The ENG-implant has both well established safety and efficacy for up to 3 years. Pharmacokinetic data on ENG show high levels at 3 years and some previous clinical research confirms efficacy beyond the current approved duration of 3 years. Today, many women, because the labeled duration has been reached, have the ENG implant removed at 3 years, increasing costs, inconvenience and risks. STUDY DESIGN SIZE, DURATION For the first 3 years, this study was an open-label, multi-centre randomized trial comparing the 3-year ENG implant to the 5-year levonorgestrel (LNG)-releasing implant. After 3 years, a subset of 390 ENG participants, consented to extended use. We compared efficacy, side effects and removal procedures of both implants. We used Kaplan–Meier (K–M) analysis. We included an observational cohort of copper intrauterine device (IUD) users as non-users of hormonal contraceptive method for comparative purposes. PARTICIPANTS/MATERIALS, SETTING, METHODS The study took place in family planning clinics in seven countries worldwide. Women were enlisted after an eligibility check and informed consent, and 1328 women were enrolled: 390, 522 and 416 in the ENG-implant, LNG-implant and IUD groups, respectively. MAIN RESULTS AND THE ROLE OF CHANCE Over 200 women used the ENG implant for at least 5 years. No pregnancies occurred during the additional 2 years of follow up in the ENG or LNG implant group. The overall 5-year K–M cumulative pregnancy rates for ENG- and LNG- implants were 0.6 per 100 women-years (W-Y) [95% confidence interval (CI): 0.2–1.8] and 0.8 per 100 W-Y [95% CI: 0.2–2.3], respectively. Complaints of bleeding changes were similar; however, ENG-users were more likely than LNG-users to experience heavy bleeding (p

The UK has one of the widest ranges of contraception available; yet, one-third of pregnancies remain unplanned. In response to the Department of Health's National Strategy for Sexual Health and HIV, the National Institute for Health and Clinical Excellence (NICE) produced guidelines on long-acting reversible contraception (LARC). LARC is promoted as an effective way to reduce unintended pregnancies. The National Strategy specifically emphasized the need for primary care teams to support women in making informed choices about their contraceptive options. This article discusses one form, the contraceptive implant.

Background: Uptake of long-acting reversible contraception (LARC) in Australia is low. With appropriate training, practice nurses (PNs) in general practice clinics could help increase LARC uptake. Methods: General practitioners (GPs) and PNs completed a postal survey to assess contraceptive implant knowledge and attitudes towards PNs providing contraception counselling and inserting the contraceptive implant. χ2 tests were used to detect differences between GPs and PNs. Unadjusted odds ratios (OR) for the association between demographic characteristics and knowledge and attitudes towards the contraceptive implant were calculated for GPs and PNs separately. Results: Four hundred and sixty-eight GPs and 1142 PNs participated. GPs had greater knowledge about LARC than PNs (59% vs 33%; P

Background Mifepristone alone or in combination with ethinyl estradiol (EE) can effectively stop an episode of uterine bleeding in women using the etonogestrel-releasing contraceptive implant, Implanon® but could impair contraceptive efficacy. Aim To examine the effects of administration of mifepristone alone or with EE on ovarian function and cervical mucus consistency in women using Implanon. Study Design Women using Implanon were randomized to mifepristone 25 mg twice daily on day 1 plus placebo 1 daily for 4 days or plus EE 20 mcg daily for days 2–5. Measurements of serum estradiol (E2), progesterone (P4), luteinizing hormone (LH), follicle-stimulating hormone (FSH), cervical mucus examination and maximal follicle size (by vaginal ultrasound) were carried out at various times. Results Following mifepristone intake, there was a dramatic increase in E2 levels ranging from 543 to 1183 pmol/L (p=.000), which was not correlated with maximal follicle size or preceded by LH or FSH increase. The increase in E2 triggered an LH increase resulting in development of a luteinized follicle in four women with no evidence of ovulation. One of these women had estradiol and progesterone levels suggestive of ovulation, but no corpus luteum was seen. Almost all women had very low mucus scores, which did not correlate with E2 levels. Discussion Despite a transient increase in E2 levels after mifepristone, there was no evidence of subsequent ovulation irrespective of whether they also received EE. The mechanism by which mifepristone in the presence of etonogestrel results in a rapid increase in E2 levels remains unclear and could not be related to any significant changes in FSH, LH, ovarian follicle dynamics or subsequent possible ovulation. Conclusion Pregnancy is very unlikely to occur if mifepristone and EE are given during use of Implanon to stop an episode of bleeding.

Adolescent women have a high risk of unintended pregnancy. Currently, there are little data about their choice to initiate long-acting reversible contraception (LARC).We evaluated the association of age and preference for a LARC vs. a non-LARC method among adolescent participants in the Contraceptive CHOICE Project, comparing those aged 14-17 years to adolescents aged 18-20 years. We then analyzed the association between age and choice of the implant vs. the intrauterine device (IUD) among adolescents.Of the 5086 women enrolled, 70% (n=3557) of participants chose a LARC method. Among adolescents aged 14-20 years, 69% of 14-17-year-olds chose LARC, while 61% of 18-20-year-olds chose LARC (relative risk 1.16, 95% confidence interval 1.03-1.30). Among adolescents choosing a LARC method, 63% (n=93/148) of the 14-17-year-olds chose the implant, whereas 71% (n=364/510) of the 18-20-year-olds chose the IUD.Long-acting reversible contraception use is clearly acceptable and common among adolescents enrolled in the Contraceptive CHOICE Project, with the younger group being most interested in the implant.

Study was conducted to determine acceptability, efficacy, safety, return of fertility with Implanon.Volunteers having regular menstruation, requiring spacing formed study population. Implanon was inserted within 5 days of LMP or concurrent with MTP. Woman was asked to record bleeding pattern, side effects. Implanon duration was 3 years but Implanon was removed before, if patient wanted pregnancy/for side effects. Subjects who did not adopt family planning method after removal were followed up for return of ovulation and pregnancy.200 subjects were enrolled (160 within 5 days of LMP, 40 concurrent with MTP). 74 implanon removals were done. (16 after tenure completion, 58 for other reasons.) 16% cases discontinued implanon for polymenorrhagia, 10% for irregular bleeding, 4.5% for amenorrhea. There was no failure of implanon. 40% had return of ovulation within one month, 95.8% conceived within 12 months.Implanon is safe, effective, well accepted method of contraception.

OBJECTIVE: : To evaluate lactogenesis after early postpartum insertion of the etonogestrel contraceptive implant. METHODS: : Healthy peripartum women with healthy term newborns who desired the etonogestrel implant for contraception were randomly assigned to early (1-3 days) or standard (4-8 weeks) postpartum insertion. The primary outcomes time to lactogenesis stage II and lactation failure were documented by a validated measure. The noninferiority margin for the mean difference in time to lactogenesis stage II was defined as 8 additional hours. Secondary data (device continuation and contraceptive use breast milk analysis supplementation rates side effects and bleeding patterns) were collected at periodic intervals for 6 months. RESULTS: : Sixty-nine women were enrolled. Thirty-five were randomly assigned to early insertion and 34 to standard insertion. There were no statistically significant differences between the groups in age race parity mode of delivery use of anesthesia or prior breastfeeding experience. Early insertion was demonstrated to be noninferior to standard insertion in time to lactogenesis stage II (early: [mean+/-standard deviation] 64.3+/-19.6 hours; standard: 65.2+/-18.5 hours mean difference -1.4 hours 95% confidence interval [CI] -10.6 to 7.7 hours). Early insertion was also demonstrated to be noninferior to standard insertion in incidence of lactation failure (1/34 [3%] in the early insertion group 0/35 [0%] in the standard insertion group [risk difference 0.03 95% CI -0.02 to 0.08]). Use of formula supplementation was not significantly different between the groups. Milk composition at 6 weeks was not significantly different between the groups. CONCLUSION: : Breastfeeding outcomes were similar in women who underwent early compared with standard postpartum insertion of the etonogestrel implant. CLINICAL TRIAL REGISTRATION: : ClinicalTrials.gov www.clinicaltrials.gov NCT00847587. LEVEL OF EVIDENCE: : I.

This study compares whether counselling style prior to insertion of subdermal implants (SDIs) affects continuation rates at one-year post-insertion. Two senior doctors in a North London Integrated Sexual Health Clinic counselled patients in different ways.This was a study involving 50 patients. Of these 25 received 'cautious' counselling: they were advised to think carefully about having a SDI inserted and the counsellor emphasised the risks and relative inconvenience of inserting and removing the implant. The second group of 25 women received 'just-try-it' counselling; this consisted of encouraging the patients to have a SDI inserted and emphasising the reversibility of the method.Continuation rates were 92% (23/25) for the 'cautious' approach and 80% (20/25) for the 'just-try-it' approach. More SDI acceptors in the 'just-try-it' group (5/25) first learned about the existence of this contraceptive method during the same consultation in which the implant was inserted than in the 'cautious' group (1/25). All six of these immediate acceptors kept their implant for at least a year.Continuation rates did not differ much between the two counselling styles and approaches were compatible with high continuation rates. Lowering the barriers to SDI use can benefit patients and reduce costs to the health economy.

AIM: While contraceptive methods increased in number the number of abortions has remained stable. The aim of this study was to estimate the satisfaction of women toward a contraceptive implant (Implanon((R))) available in France in order to clarify prescription. METHOD: The survey concerned 127 women who visited Angers and Nantes family planning centres between January2009 and January2010 in two implant prescription contexts (postabortion or not). They agreed to answer a first questionnaire describing the reasons for their choice. A second questionnaire was sent six months after to assess its tolerance. RESULTS: In our study 82% of patients were using a contraceptive method prior to implant (68% in postabortion and 88% in the other group). The first reason for choosing the implant was the fear of forgetting - it was more important in the postabortion group (88% vs. 61%). The main side effects were amenorrhea (50%) weight gain (30%) and mood disorders (19%). More than one in two women (54%) was very satisfied by the implant. It should be noted that in one quarter of cases women seek early withdrawal of the contraceptive implant (23% in postabortion and 21% in the other group) a rate that is 39% in patients under 25years and 47% in patients who reported a mood disorder. CONCLUSION: There is a tendency to better tolerance of the implant out of a context of abortion. Furthermore mood disorders appear to be poorly tolerated. These elements encourage greater caution in prescribing the contraceptive implant in postabortion situation in which patients have already psychological disorders and even more among younger patients. Copyright (c) 2010 Elsevier Masson SAS. All rights reserved.

This article focuses on Implanon the subdermal contraceptive implant. It describes Implanon and how it works in addition to providing information on: the appropriate timing of insertion side effects and acceptability discontinuation of Implanon Implanon and lactation metabolic effects bone mineral density (BMD) effects Implanon use in obese patients contraindications return to fertility and counseling patients.

To address the gap in the uptake of long-acting contraception (LAC) methods among high-risk postpartum women who fail to return for a family planning method at HôpitalUniversitaire de Mirebalais in the Central Plateau Department of Haiti, contraceptive implant trainings were held for providers on the Labour and Delivery, Post-Partum and Internal Medicine inpatient wards.A very high maternal mortality rate affects large numbers of women in Haiti; however, contraceptive use can reduce maternal mortality significantly. A quality improvement strategy to offer LAC methods to immediate postpartum women at a University Hospital in rural Haiti was initiated in March 2016. This new strategy produced an average improvement from 5% to 32% of women delivering at the hospital, accepting a long-acting method (including bilateral tubal ligations) by the end of the project and which has proved sustainable at an average of 20% to date.

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.

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.

The US Food and Drug Administration will apply unprecedented restrictions on the use of Bayer’s contraceptive implant Essure after finding that previous warnings did not do enough to inform patients about the device’s potential risks. Effective immediately, the only healthcare facilities allowed to implant the device will be those that agree that, in every case, a healthcare professional will guide prospective recipients through a 20 page, FDA approved brochure laying out potential adverse effects.1 Informed …

Sino-implant (II) is a subdermal contraceptive implant manufactured in China. This two-rod levonorgestrel-releasing implant has the same amount of active ingredient (150 mg levonorgestrel) and mechanism of action as the widely available contraceptive implant Jadelle. We examined randomized controlled trials of Sino-implant (II) for effectiveness and side effects.We searched electronic databases for studies of Sino-implant (II) and then restricted our review to randomized controlled trials. The primary outcome of this review was pregnancy.Four randomized trials with a total of 15,943 women assigned to Sino-implant (II) had first-year probabilities of pregnancy ranging from 0.0% to 0.1%. Cumulative probabilities of pregnancy during the 4 years of the product's approved duration of use were 0.9% and 1.06% in the two trials that presented date for 4-year use. Five-year cumulative probabilities of pregnancy ranged from 0.7% to 2.1%. In one trial, the cumulative probability of pregnancy more than doubled during the fifth year (from 0.9% to 2.1%), which may be why the implant is approved for 4 years of use in China. Five-year cumulative probabilities of discontinuation due to menstrual problems ranged from 12.5% to 15.5% for Sino-implant (II).Sino-implant (II) is one of the most effective contraceptives available today. These available clinical data, combined with independent laboratory testing, and the knowledge that 7 million women have used this method since 1994, support the safety and effectiveness of Sino-implant (II). The lower cost of Sino-implant (II) compared with other subdermal implants could improve access to implants in resource-constrained settings.

This essay examines the history of Norplant from its development in the 1960s, to its approval by the FDA in 1990, through its tumultuous reception in American society, to its removal from the market in 2000. The rejection of Norplant by women was influenced by the social and political climate of the 1990s, in which a feminist health agenda, a consumerist ideology in health care, a growing tendency toward class action litigation, and increasing distrust of the pharmaceutical industry worked together to empower women to take charge of their reproductive decision making. The rhetoric of population control in the 1960s, when the pill and IUD were introduced, was very different from the language of individual choice that dominated in the 1990s, the era of Norplant. This investigation of Norplant extends the historical analysis of reproductive politics to the very end of the twentieth century.

Objective We sought to determine satisfaction and continuation rates of the contraceptive implant when placed on the initial visit for first-trimester medical abortion. Study Design In this pilot study, we placed the implant within 15 min of mifepristone administration. We assessed satisfaction with implant placement timing, 1-year implant continuation and abortion completion. Results We enrolled 20 participants. Sixteen (80%) returned for follow-up, and all had complete abortion. At 1 year, of 16 participants contacted, 14 (87.5%) were satisfied with implant insertion timing, and 14 (87.5%) continued the implant. Conclusions Initiation of the contraceptive implant on the initial visit for medical abortion resulted in high satisfaction and continuation rates. Implications This pilot study provides important groundwork for future larger studies to assess initiation of the contraceptive implant on the day of mifepristone for medical abortion.

Rationale To report the distant migration of a subdermal contraceptive implant and to suggest that C arm-guided technique is one of the feasible options for removal of the device migrated to the axilla. Patient concerns A 41-year-old multipara with tingling sensation in the left axilla was referred for removal of an Implanon NXT which could not be palpated by physical examination or detected by ultrasound scanning. Finally, the device was detected by computed tomography and found migrating to the left axilla. Diagnosis Migration of Implanon NXT to the left axilla abutting the brachial plexus. Interventions The device was removed by C arm-guiding. Outcomes The patient went home without any procedure-related complications. Lessons The incidence of distant migration of a subdermal implant is possible and should be checked up regularly. If the device cannot be palpated or detected by ultrasound at the original implanting site, this should be concerned. Since the single-rod subdermal implant is radiopaque, it can be detected by roentgenography. In this case the distant migration was detected in the axilla, therefore using C arm-guided technique is feasible for the removal of the migrating device. After reviewing the literature, totally 10 cases of distant migration were reported including 2 cases of migration which were advanced further to the pulmonary artery as an embolization.

BackgroundUse of long-acting, highly effective contraception has the potential to improve women's ability to avoid short interpregnancy intervals, which are associated with an increased risk of maternal morbidity and mortality, and preterm delivery. In Uganda, contraceptive implants are not routinely available during the immediate postpartum period.ObjectiveThe purpose of this study was to compare the proportion of women using levonorgestrel contraceptive implants at 6 months after delivery in women randomized to immediate or delayed insertion.Study designThis was a randomized controlled trial among women in Kampala, Uganda. Women who desired contraceptive implants were randomly assigned to insertion of a 2-rod contraceptive implant system containing 75 mg of levonorgestrel immediately following delivery (within 5 days of delivery and before discharge from the hospital) or delayed insertion (6 weeks postpartum). The primary outcome was implant utilization at 6 months postpartum.ResultsFrom June to October 2015, 205 women were randomized, 103 to the immediate group and 102 to the delayed group. Ninety-three percent completed the 6 month follow-up visit. At 6 months, implant use was higher in the immediate group compared with the delayed group (97% vs 68%; P < .001), as was the use of any highly effective contraceptive (98% vs 81%; P= .001). Women in the immediate group were more satisfied with the timing of implant placement. If given the choice, 81% of women in the immediate group and 63% of women in the delayed group would choose the same timing of placement again (P= .01). There were no serious adverse events in either group.ConclusionOffering women the option of initiating contraceptive implants in the immediate postpartum period has the potential to increase contraceptive utilization, decrease unwanted pregnancies, prevent short interpregnancy intervals, and help women achieve their reproductive goals.

Background: User profile, continuation rate, reasons for discontinuation, problems during insertion and removal, and effectiveness of an etonogestrel subdermal contraceptive implant (ESCI) were assessed. Study Design: A follow-up of 372 women 3 years after insertion of an ESCI performed by family physicians in Granada, Spain, by means of consultations, examination of medical records and telephone interviews. Results: Data were available for 356 (95.7%) women. The average age was 27.2 years, and 159 (42.7%) were nulliparous. Continuation rates were 91.0% at 1 year, 74.7% at 2 years and 65.1% at 2 years and 9 months. The main reasons for discontinuation were excessive bleeding (44, 12.4%), wish to become pregnant (44, 12.4%) and side effects not related to menstruation (21, 5.9%). However, 141 (39.6%) received a second implant when the first one expired. No pregnancy occurred in 893.4 women-years. Conclusions: Family physicians can achieve excellent results with the ESCI. It should be included in the range of contraceptives offered by primary care physicians.

Objective To present efficacy, safety, and bleeding profile results from the clinical trials that supported the U.S. Food and Drug Administration filing for the approval of a single-rod etonogestrel (ENG) contraceptive implant (Implanon). Design Integrated analysis of 11 international clinical trials. Setting Contraceptive clinics in U.S., Chile, Asia, and Europe. Patient(s) A total of 942 healthy women, aged 18 to 40 years. Intervention(s) Insertion of an ENG implant. Most women were enrolled in studies lasting either 2 or 3 years. Main Outcomes Measure(s) Efficacy was measured by the cumulative Pearl Index in women ≤35 years old. Safety was primarily assessed by incidence of adverse events. Bleeding profiles were analyzed via reference period analyses. Result(s) No pregnancies were reported while the ENG implants were in place. Six pregnancies occurred during the first 14 days after ENG implant removal. Including these six pregnancies, the cumulative Pearl Index was 0.38 (year 1 and 2 Pearl Indexes were 0.27 and 0.30, respectively). Common drug-related adverse events were headache, weight gain, acne, breast tenderness, emotional lability, and abdominal pain. Bleeding pattern changes were observed, but no one pattern predominated. Conclusion(s) The ENG implant is an efficacious and safe method of contraception which does not require patients' consistent action.

• The majority of women use the less reliable methods of contraception. • The majority of oral contraceptive users miss two or three pills per packet. • Thinking has changed from promoting user-dependent to user-independent contraceptive methods. • Intrauterine devices do not cause pelvic infection or ectopic pregnancy. • There is no lower age limit for users of any long-acting reversible contraceptives, including intrauterine devices. Learning objectives: • To understand the advantages of user-independent methods of contraception. • To be able to combat myths and misunderstandings relating to them. Ethical issues: • Fraser competence should be sought whenever a new method of contraception is chosen by someone under 16 who is not involving their parents in their decision. • Some people may find the intrauterine copper device unacceptable, as one of its contraceptive actions may be to prevent an embryo from implanting. Please cite this article as: Fleming CF. Long-acting reversible contraceptives. The Obstetrician & Gynaecologist 2009;11:83–88.

To determine whether the use of the subdermal contraceptive implant releasing etonogestrel (Implanon) affects serum hormonal and biochemical indices.Seventy women with a mean age of 28.5+/-3.4 years were enrolled into this prospective observational study. After placement of an Implanon rod, they were followed-up for three years. Baseline and end-of-study values of serum low-density lipoprotein (LDL), high-density lipoprotein (HDL), cholesterol, triglycerides, fasting glucose, blood urea nitrogen (BUN), creatinine, SGOT, SGPT, follicle stimulating hormone (FSH), luteinizing hormone (LH), oestradiol, free 3,5,3'-tri-iodothyronine (fT3), free thyroxine (fT4), thyroid stimulating hormone (TSH), and prolactine (PRL) were compared using Student's t-test.There was no failure of contraception during the three year period. No statistically significant differences were observed between the initial and final levels of fasting blood glucose, BUN, SGOT, SGPT, LDL, HDL, E2, FSH, LH, fT3, fT4 and TSH (p0.05), but the increase in PRL, cholesterol and triglycerides, and the decrease in creatinine levels at the end of three years were statistically significant (p0.05) although the values were still within normal ranges.Our findings confirm data from the literature according to which Implanon does not affect meaningfully reproductive hormonal parameters, thyroid function, hepatic and renal functions, and glucose metabolism. However, further studies are needed to elucidate lipid metabolism changes.

The retention of a foreign body during a surgical procedure or the inadvertent migration of an implant are rare but potentially harmful complications. Especially in the case of the former, the legal situation is unequivocal. Nevertheless, the uncomplicated removal and limitation of the operative trauma may be in the interest of the surgeon. We report and illustrate 2 patients in whom the use of intra-operative ultrasound resulted in the safe and elective removal of an intracranial drill tip in one patient and a contraceptive implant located in the ulnar nerve sheath in the other. The characteristic acoustic shadowing artefact could be demonstrated in both examples. In the first patient, intra-operative magnetic resonance tomography could not be used because of the magnetic artefact, and in the second patient, ultrasound was preferred for reasons of simplicity. Intra-operative ultrasound is an appropriate and easily available tool for detection of small foreign bodies beneath the nervous system. The neurosurgeon should be familiar with the typical characteristics of foreign bodies, which is different from other structures.

Deep etonogestrel contraceptive implant placements still occur despite design modifications to the implant inserter. We present a method for outpatient removal of a nonpalpable etonogestrel implant using preprocedure ultrasonography for implant localization followed by removal with a modified vasectomy clamp, a modification of the "U" technique for six-capsule levonorgestrel implant removal.In women with a nonpalpable etonogestrel implant containing barium sulfate, we obtain a radiographic examination to confirm the implant's presence in the upper extremity. Using an 18-MHz linear ultrasound transducer, we identify and mark the implant location on the patient's arm, noting the depth. We remove the implant with local anesthesia in the office using a modified vasectomy clamp through a 5-mm or less skin incision directly over the implant.All three patients referred to our office with nonpalpable etonogestrel implants had successful removal using this technique.Nonpalpable contraceptive implants can be removed in the office using a modified vasectomy clamp after localization with high-frequency ultrasonography. Given the relative infrequency of nonpalpable implant removals, regional expert sites with health care providers experienced in difficult removals should be created for patient referrals.

Objective This survey of published researchers of long-acting reversible contraceptives (LARCs) examines their opinions about important barriers to LARC use in the United States (US), projections for LARC use in the absence of barriers and attitudes toward incentives for clinicians to provide and women to use LARC methods. Study design We identified 182 authors of 59 peer-reviewed papers on LARC use published since 2013. A total of 104 completed an internet survey. We used descriptive and multivariate analyses to assess LARC use barriers and respondent characteristics associated with LARC projections and opinions. Results The most commonly identified barrier was the cost of the device (63%), followed by women’s knowledge of safety, method acceptability and expectations about use. A shortage of trained providers was a commonly cited barrier, primarily of primary care providers (49%). Median and modal projections of LARC use in the absence of these barriers were 25–29% of contracepting women. There was limited support for provider incentives and almost no support for incentives for women to use LARC methods, primarily out of concern about coercion. Conclusions Clinical and social science LARC experts project at least a doubling of the current US rate of LARC use if barriers to method provision and adoption are removed. While LARC experts recognize the promise of LARC methods to better meet women’s contraceptive needs, they anticipate that the majority of US women will not choose LARC methods. Reducing unintended pregnancy rates will depend on knowledge, availability and use of a wider range of methods of contraception to meet women’s individual needs. Implications Efforts to increase LARC use need to meet the dual goals of increasing access to LARC methods and protecting women’s reproductive autonomy. To accomplish this, we need reasonable expectations for use, provider training, low-cost devices and noncoercive counseling, rather than incentives for provision or use.

Objective: Many forms of contraception are available on prescription only for example, the oral contraceptive pill (OCP) and long-acting reversible contraceptives (LARCs). In this analysis we aim to identify key determinants of prescription contraceptive use.Design: Cross-sectional population survey. Data on sociodemographic indices, concerns about the OCP and perceived barriers to access were collected.Setting: Data set constructed from a representative population-based telephone survey of community dwelling adults in the Republic of Ireland (RoI)Participants: 1515 women aged between 18 and 45?yearsMain outcome measure: Self-reported user of the OCP or LARCs (intrauterine contraception, contraceptive injections or subdermal contraceptive implants) in the previous 12?months.Results: For at least some of the previous year, 35% had used the OCP and 14% had used LARCs, while 3% had used two or more of these methods. OCP users were significantly younger, more likely to be unmarried and had higher income than non-users. Overall, 68% agreed with the statement ‘that taking a break from long-term use of the contraceptive pill is a good idea’ and 37% agreed with the statement that ‘the OCP has dangerous side effects’ and this was the strongest predictor variable of non-use of the OCP. Intrauterine contraception users were significantly older, more likely to be married and had lower income than non-users. Injections or subdermal contraceptive implant users were significantly younger, less likely to be married, had lower income and were less likely to agree that taking a break from long-term use of the pill is a good idea than non-users.Conclusions: Prescription contraceptive use is sociodemographically patterned, with LARCs in particular being associated with lower incomes in the RoI. Concerns about the safety of the OCP remain prevalent and are important and modifiable determinants of contraceptive-related behaviour.