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Objective The objective of this analysis was to present our secondary outcomes (reach, adoption, implementation, maintenance domains) of a prospective trial to test the efficacy of a home-based intervention to increase postpartum contraceptive uptake. Study Design We executed a cluster-randomized trial to determine if provision of contraception in the home setting increased uptake of postpartum methods. We collected secondary outcomes on how our implementation strategies of revising professional roles and changing service sites performed in terms of the number of people our study enrolled of all women eligible (reach), how it was accepted by the providers (adoption), what methods were used to conduct the study (implementation), and preliminary results on whether or not the intervention will be continued (maintenance). We conducted a survey and focus group discussion to assess adoption and implementation among intervention nurse staff, and a survey in a convenience sample of patients in the intervention arm to assess acceptability. Results Our primary outcome of effectiveness has been published; implant uptake was 25% in the intervention cohort compared to 3% in the control clusters. Our reach was 89%, as 208 of the 234 eligible women consented to participate. Among a convenience sample of N = 25 patients completing a survey on the intervention 12 months after enrollment, ≥ 68% (n = 17 of 25) felt the intervention was acceptable. From the nursing perspective (N = 7), only a minority of nurses felt the intervention was complicated (n = 1, 17%), and (n = 7, 100%) reported the intervention was acceptable. Conclusions Our intervention achieved good reach (89% of the eligible population) and was acceptable to the majority of patients and providers. Practitioners interested in achieving greater reach of contraceptive interventions in their communities may consider changing service sites to convenience their clients, as our results suggest this approach was acceptable. Implications The unique contribution of this paper is in its success with training nurses to insert contraceptive implants during postpartum home visits, which resulted in increased uptake of the contraceptive implant where access to the device was previously limited. Given the trial's successful feasibility and acceptability to both nurses and patients, perhaps this intervention has the potential to be adapted and scaled to other settings.

Design: We executed a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with three and 12-month contraceptive utilization, satisfaction, and pregnancy rates.Methods: Eight clusters were randomized to receive either the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit in addition to routine care, or routine care alone, which included comprehensive contraceptive counseling throughout antepartum care. Results: 208 women were enrolled in the study, 108 in the intervention clusters and 100 in control clusters. 94 (87.0%) women in the intervention group and 91 (91%) of women in control clusters were evaluated 12 months post-enrollment. Likelihood of using contraception at that time was borderline increased in intervention clusters (RR 1.1 [1.0,1.3], p = 0.05) with an increased likelihood of long-acting contraceptive use (the implant; RR 1.6 [1.3,1.9], p < 0.001). Pregnancy rates were also borderline reduced in the intervention clusters (RR 1.0 [1.0,1.1], p = 0.07). There was no difference in satisfaction of women with contraceptive use between arms with about 95% of women very satisfied or a little satisfied in each arm. Continuation rates at twelve months of contraceptives in the intervention group were 0.0% for condom users, 80.0% for contraceptive pill users, 57% for injectable users, and 83% for implant users. Most women who discontinued their initial method chose a more long-term or permanent method. There was a trend toward a significant association with reduced short interval pregnancy.Conclusion: Our study had a borderline increase in overall use of contraception by 12 months, did have an increased likelihood of long-acting contraceptive use of the implant by 12 months, and resulted in a trend toward reduced short interval pregnancy in the intervention clusters as compared to control clusters. Registration: clinicaltrials.gov, NCT04005391; Retrospectively Registered 7/2/2019, https://clinicaltrials.gov/ct2/show/NCT04005391Protocol: https://doi.org/10.1186/s13063-019-3735-3

PURPOSE: To explore how diet and exercise habits associate with serum etonogestrel concentrations among contraceptive implant users. MATERIALS AND METHODS: We conducted a secondary analysis of healthy, reproductive-age women using etonogestrel implants. This study was registered on ClinicalTrials.gov, NCT03092037. We assessed diet and exercise habits with two validated surveys: Healthy Eating Vital Signs and the Stanford Brief Activity Survey. Participants previously had their serum etonogestrel concentrations measured using a validated liquid-chromatography mass-spectrometry assay. We then used linear modeling to test for associations between survey responses and serum etonogestrel concentrations. RESULTS: Among 129 participants, diet and exercise habits had no significant associations with serum etonogestrel concentrations (p= 0.22–0.72), with inconsistent effects found for increased caloric intake and sedentary lifestyle. CONCLUSION: This exploratory study found no significant effect of diet or exercise habits on steady-state pharmacokinetics among contraceptive implant users.

Introduction. The maternal mortality ratio (MMR) in Indonesia reaches 359 per 100,000 live births. The long-acting reversible contraceptive (LARC) method is an effective contraceptive choice for reducing MMR. The contraceptive implant is one of the LARCs that has low usage due to lack of education about the side effects. This study aims to compare the menstrual pattern and characteristics between one-rod and two-rod levonorgestrel implant users. Methods. A prospective cohort study was performed in patients at Cipto Mangunkusumo Hospital (RSCM) from March 2016 to May 2018. Subject recruitment was done by consecutive sampling. This study was conducted from March 2016 until May 2019. Statistical analysis was performed on the data using the chi-square test to determine the relationship between menstrual pattern and characteristics, and the use of one-rod or two-rod levonorgestrel implants. Results. A total of 140 subjects participated in the study, comprising 70 (50%) one-rod users and 70 (50%) two-rod users. In the first month, 32.9% one-rod users experienced amenorrhea, 22.9% experienced shortened menstrual period, 30% experienced normal menstrual period, and 14,2 % experienced lengthened menstrual period. In comparison, in the first month, 41.4% two-rod users experienced amenorrhea, 15.7% experienced shortened menstrual period, 32.9% experienced normal menstrual period, and 10% experienced lengthened menstrual period. There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users. Conclusion. There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users. Implications. Menstrual patterns and characteristics from levonorgestrel implants user can help clinicians to reduce discontinuation rate from the acceptors. Further research should be conducted to know other side effects aside from menstrual bleeding patterns.

Introduction: Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers’ and participants’ satisfaction with an intervention used in a large trial in Sweden. Material and methods: A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice. Trial registration: ClinicalTrials.gov (NCT03269357). Results: Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package. Conclusions: The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods. © 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG)

Endometriosis is a chronic estrogen-dependent gynecological disease characterized by the presence of endometrial tissue (stroma and/or glands) outside the uterine cavity, which induces a chronic, inflammatory reaction. Most commonly this involves ovaries and fallopian tubes, and rarely endometrial tissue may spread beyond pelvic organs.

BackgroundFamily planning services have been available at no cost in the public health settings of South Africa since 1994, and now include the long-acting reversible contraceptives (LARCs) namely, the contraceptive implant and intra-uterine device (IUD). However, the uptake of LARCs has been declining in the recent years and little is known about the cause of the decline. In many relationships, men may influence their female intimate partner’s contraceptive choices. Thus, men’s involvement in reproductive health decisions and family programming may improve their support for contraceptive use, including the LARC use by their female intimate partners. This study investigated factors affecting men’s support for the use of contraceptive implant by their female intimate partners.MethodsA quantitative, cross-sectional survey was conducted among adult men attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, we measured men’s knowledge, awareness and support of, and attitudes towards use of the contraceptive implant by their female intimate partners. Data were analyzed using SPSS version 25.ResultsThe sample included 65 men with a mean age of 31.2 years. Most (76.6%) believed that both men and women should be responsible for family planning. Support for general contraception use by their female intimate partners was prevalent at 80.0%, but only 33.9% reported that they would like their partners to use the implant in the future, while 35.6% were unsure and 30.5% did not support their partner’s use of the implant. Factors significantly associated with men’s support of their partner’s future use of the contraceptive implant included men’s reports that their partner wished to have another child in future, knowledge that the implant is safe for use by women who have not had children, knowledge that the implant can effectively prevent pregnancy for 3 years, and a positive attitude towards the implant’s long-lasting effectiveness.ConclusionImproving men’s knowledge of, and attitudes toward the contraceptive implant might increase their support for their partner’s use of the implant, which in turn might promote uptake of the implant among women. The findings of our study suggest the importance of actively engaging men in reproductive health and family planning programs.

Design This a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with implant utilization rates at 3 months post-enrollment. Methods In a region of rural Guatemala referred to as the Southwest Trifinio, twelve communities are served by a community-based antenatal and postnatal care program. The communities were combined into eight clusters based on 2017 birth rates and randomized to receive the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit. All participants receive comprehensive contraceptive counseling beginning at the first antenatal visit, so control clusters received this as part of routine care; this education preceded the study intervention. Results Once the 12 communities were combined into 8 clusters by expected birth volume and nurse team, which we expected to translate to eventual postpartum visits, the allocation sequence was generated in SAS. Of 208 women enrolled in the study, 108 were in four intervention and 100 in four control clusters. We used descriptive statistics to produce counts and percentages of characteristics of the study population overall and by intervention arm followed by univariate modeling using a mixed effects regression adjusted for cluster. Three-month contraceptive initiation rates were 56.0% in the control clusters compared to 76.8% in the intervention clusters, p p p Conclusion Our study was designed to respond to previously identified barriers to contraceptive uptake, and it was successful. Not only did it increase overall use of contraception by 3 months, but it shifted that contraceptive use away from short-acting methods in favor of longer-acting methods, with high continuation and satisfaction rates and no adverse outcomes reported. Trial registration clinicaltrials.gov, NCT04005391; Retrospectively Registered 7/2/2019

The aim of this study was to provide evidence to policy makers on cost effectiveness and budget impact for the introduction of the etonorgestrel implant into the Indian public health system. An economic evaluation was conducted to ascertain the potential costs and outcomes of adding the etonorgestrel implant to the public health system of India as compared to the current scenario. A decision analytical model (Markov cohort) was conceptualized from a societal perspective, where a hypothetical population of 15-year-old females was followed until menopause. The primary outcome was incremental cost-utility ratio (ICUR). Sources for model inputs included country-level secondary data analysis, government reports, an observational primary costing study, a systematic review of etonorgestrel implant and targeted literature reviews. One-way and probabilistic sensitivity analyses (OWSA and PSA) were performed to account for uncertainty. The impact of etonorgestrel implant introduction on the annual Indian health budget was also analysed. The base-case ICUR was 16,475 Indian rupees (INR) (USD 232) per quality-adjusted life-year gained, which showed the etonorgestrel implant to be very cost effective (ICUR below willingness-to-pay threshold of INR 137,945 [USD 1943]). OWSA showed that discount rate, percentage of people who do not use contraceptives and costs of managing side effects were the important parameters that affected ICUR. PSA showed that ICUR values of all 1000 Monte Carlo simulations were cost effective. Budget impact analysis showed that introduction of the implant would account for

Background Subdermal contraceptive implant is the most widely used method of long-acting reversible contraception among Ethiopian women. Many, however, discontinue use early, which results in unwanted pregnancies and induced abortions and their associated complications. The aim of this study is to determine the rate of and reasons for discontinuation of the contraceptive implant among users in the Kersa district of southwestern Ethiopia. Methods A mixed-method study was carried out between March and April 2019 among 475 women who had been using the contraceptive implant between January 2015 and August 2016 in the Kersa district. Systematic random sampling was used for quantitative data collection and purposive sampling was used for qualitative data collection using 8 focus group discussion and 56 In-depth interviews. A binary logistic regression was carried out for bivariate and multivariable analyses. Results One hundred and ten (23.2 %) contraceptive implant users requested removal before 2.5 years of use. The main reasons for the discontinuation were side effects, followed by a desire for pregnancy or to switch to another contraceptive method and misconceptions. Implant discontinuation was associated with a lack of information prior to insertion on the effectiveness of modern contraception (adjusted odds ratio [OR] 2.0; 95 % confidence interval [CI] 1.13, 3.55), being served by a midwife or nurse (adjusted OR 1.8; 95 % CI 1.04, 3.23), and not being told to return to the health facility if any side effects were experienced (adjusted OR 1.8; 95 % CI 1.01, 3.19) (all p Conclusions Almost a quarter of the study participants discontinued use of the contraceptive implant before the due date. Public health interventions should focus on providing adequate awareness for family planning users, trainings for the health care workers on effective counselling services, especially on side effect and misconceptions.

Objective To evaluate whether a short course of tamoxifen decreases bothersome bleeding in etonogestrel contraceptive implant users. Methods In a 90-day, double-blind randomized control trial, we enrolled etonogestrel implant users with frequent or prolonged bleeding or spotting. A sample size of 40 per group (N=80) was planned to compare 10 mg tamoxifen or placebo twice daily for 7 days after 3 consecutive days of bleeding or spotting no more than once per 30 days (maximum three treatments). Participants then entered a 90-day open-label study where all received tamoxifen if needed every 30 days (maximum three treatments). Participants used text messages to record daily bleeding patterns. Our primary outcome was the total number of consecutive amenorrhea days after the first treatment. Secondary outcomes included time to bleeding or spotting cessation and restart after first treatment, overall bleeding patterns, and satisfaction. Results From January 2017 to November 2018, 112 women enrolled in the study; 88 (79%) completed 90 days, and 79 (71%) completed 180 days. Participant characteristics did not differ between groups; mean age 24, majority identified as white not Hispanic with at least some college education. After the first treatment, the tamoxifen group reported an average of 9.8 (95% CI 4.6-15.0) more consecutive days of amenorrhea and more total days of no bleeding (amenorrhea or spotting) in the first 90 days (median 73.5 [range 24-89] vs 68 [range 11-81], P=.001). The placebo group showed a similar treatment benefit after first active use of tamoxifen in the open-label phase. At the end of the randomized study (first 90 days), women who received tamoxifen reported higher satisfaction (median 62 mm [range 16-100]) than those treated with placebo (46 mm [range 0-100]; P=.023). Conclusion A short course of tamoxifen reduces problematic bleeding and improves satisfaction in users of etonogestrel implants. Clinical trial registration ClinicalTrials.gov, NCT02903121.

Background A long-acting implant for HIV pre-exposure prophylaxis (PrEP) is in development in the Sustained Long-Action Prevention Against HIV (SLAP-HIV) trial. This could provide an alternative to oral PrEP. Objective Our mixed methods study aimed to understand (1) users’ experiences with a similar subdermal implant for contraception and (2) factors influencing the likelihood that gay and bisexual men (GBM) would use a proposed PrEP implant. Methods Work was completed in 4 stages. In stage 1, we conducted a scientific literature review on existing subdermal implants, focusing on users’ experiences with implant devices. In stage 2, we reviewed videos on YouTube, focusing on the experiences of current or former contraceptive implant users (as these implants are similar to those in development in SLAP-HIV). In stage 3, individuals who indicated use of a subdermal implant for contraception in the last 5 years were recruited via a web-based questionnaire. Eligible participants (n=12 individuals who liked implants a lot and n=12 individuals who disliked implants a lot) completed in-depth phone interviews (IDIs) about their experiences. In stage 4, results from IDIs were used to develop a web-based survey for HIV-negative GBM to rate their likelihood of using a PrEP implant on a scale (1=very unlikely and 5=very likely) based on likely device characteristics and implant concerns identified in the IDIs. Results In the scientific literature review (stage 1), concerns about contraceptive implants that could apply to the PrEP implants in development included potential side effects (eg, headache), anticipated high cost of the device, misconceptions about PrEP implants (eg, specific contraindications), and difficulty accessing PrEP implants. In the stage 2 YouTube review, individuals who had used contraceptive implants reported mild side effects related to their device. In stage 3, implant users reported that devices were comfortable, unintrusive, and presented only minor discomfort (eg, bruising) before or after insertion and removal. They mainly reported removing or disliking the device due to contraceptive-related side effects (eg, prolonged menstruation). Participants in the stage 4 quantitative survey (N=304) were mainly gay (204/238, 85.7%), white (125/238, 52.5%), cisgender men (231/238, 97.1%), and 42.0% (73/174) of them were on oral PrEP. Not having to take a daily pill increased the likelihood of using PrEP implants (mean 4.13). Requiring >1 device to achieve 1 year of protection (mean range 1.79-2.94) mildly discouraged PrEP implant use. Participants did not mind moderate bruising, a small scar, tenderness, or bleeding after insertion or removal, and an implant with a size slightly larger than a matchstick (mean ratings 3.18-3.69). Conclusions PrEP implants are promising among GBM. Implant features and insertion or removal-related concerns do not seem to discourage potential users. To ensure acceptability, PrEP implants should require the fewest possible implants for the greatest protection duration.

Objective The objective of the study was to present the experience of the family planning service Hospital General de Mexico, in locating and removing no palpable subdermal single-rod contraceptive implants. Materials and methods A descriptive, prospective, and cross-sectional study was performed from January 2011 to April 2018. Results Hundred and sixty-four patients in whom the implant was not palpable were reviewed, the time between insertion and removal averaged 3.3 years (maximum 10 years and minimum 3 months). Three implants were inserted in the right arm, the rest on the left one. Forty-seven implants were found in fatty tissue (29%), 18 in fascia (11%), 94 in muscle (57%), 2 in the armpit (1.2%), and 3 were not found (1.8%). Conclusions The no palpable implant is caused by an incorrect insertion technique. Migration should not be assumed as a cause of difficult location. Amount of non-palpable implants is not possible to determine due to a lack of records, but approximately 3% are considered non-palpable. Ultrasound has proven to be the study of choice to locate an incorrect inserted implant. In this case, the total number of implants was located, except in two patients.

Among young persons, ease of use, high efficacy, and high acceptability makes the etonogestrel contraceptive implant an important choice for this age group. Adolescent-friendly, patient-centered counseling considers the patient's cognitive development, the influence of friends and family, as well as their own preferences and values. Age-appropriate language, graphics, and models are useful to explain contraceptive options and relevant side effects. Effectiveness, reversibility, safety, noncontraceptive benefits, and side effects are important attributes and should be discussed when teens are choosing a contraceptive method. In this review we describe suggested best practices for counseling adolescents about the etonogestrel implant so they can make informed, prudent decisions about using this contraceptive method.

Study Objective To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation. Design, Setting, and Participants Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up. Interventions and Main Outcome Measures Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at Results A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m2). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P Conclusions The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

Objective To explore the pharmacokinetic interaction between isotretinoin, a cytochrome P-450 (CYP) inducer and potent teratogen, and the etonogestrel contraceptive implant. Study design We enrolled healthy reproductive-age women initiating isotretinoin and using an etonogestrel implant. We compared serum etonogestrel concentrations at baseline and after four and nine weeks of isotretinoin co-administration using a validated assay. Results Among eight implant users, all serum etonogestrel concentrations remained >90 pg/mL during isotretinoin co-administration with no significant changes from baseline (p = 0.25, Friedman’s test). Conclusion In this exploratory study, we found that isotretinoin did not cause serum etonogestrel concentrations to fall below the threshold for ovulatory suppression ( Implications Reproductive-age women treated with isotretinoin require reliable contraception to prevent pregnancies impacted by teratogenic-effects. This small study demonstrates that contraceptive implant users maintained serum etonogestrel concentrations above the threshold for consistent ovulatory suppression during isotretinoin co-administration. The contraceptive implant remains an appropriate option for patients considering isotretinoin therapy.

Key messages Kristy, a 17-year-old girl, presents to clinic, having previously had a discussion of her contraceptive options with you. She is sexually active with her boyfriend and does not want to become pregnant. She feels that an implant would suit her and wishes to discuss it further as she has some concerns. Her friend had an implant, but when she requested a removal, she had to be referred to a specialist as the implant was impalpable. Her friend’s experience is putting Kristy off and she doesn’t really understand how it could have happened. Kristy’s interest in the etonogestrel contraceptive implant has been challenged by her friend’s negative experience. Close personal contacts are adolescents’ primary source of information about contraceptives.1 2 Secondhand experiences with negative side effects are prevalent and weighted more heavily in contraception choice than positive experiences.1 2 An adolescent considering the use of a device may be especially concerned about physical harm to the body. Fortunately, contraceptive counselling and the endorsement of a method …

Objectives To evaluate whether etonogestrel concentrations are reduced to a level that could potentially reduce contraceptive efficacy when the etonogestrel contraceptive implant is used concomitantly with dolutegravir-based antiretroviral therapy (ART). Study design We conducted a non-randomized, open-label, cross-sectional pharmacokinetic study among women using single-rod etonogestrel contraceptive implants in Botswana. We compared plasma etonogestrel concentrations, sampled at a single time-point between 3 and 12 months from implant insertion, among implant users living with HIV and receiving dolutegravir-based ART with HIV-negative implant users. We also assessed concentrations among implant users living with HIV and receiving efavirenz-based ART. We compared geometric mean etonogestrel concentrations analyzing data from 142 participants: 97 HIV-negative, 30 using dolutegravir, and 15 using efavirenz. Results The groups were similar. Duration of implant use was between 3 and 12 months (median = 5). Geometric mean etonogestrel plasma concentrations and 90% confidence intervals of the mean were 227.5(212.4–243.8), 289.6(251.8–333.0) and 76.4(63.9–91.4) pg/mL among the HIV-negative, dolutegravir- and efavirenz-based ART groups, respectively. All women in the HIV-negative and dolutegravir-based ART groups had etonogestrel concentrations above 90 pg/mL; 9/15 women (60%) using efavirenz-based ART had concentrations below 90 pg/mL. On average, etonogestrel levels were lower among individuals who had implants inserted for longer durations. Conclusions Implant users receiving dolutegravir-based ART had a higher mean etonogestrel concentration compared to HIV-negative women, and none had etonogestrel concentrations below the posited threshold for ovulation suppression. In contrast, women in the efavirenz-group had much lower etonogestrel concentrations. Overall, these data provide evidence that the etonogestrel implant may be effectively combined with dolutegravir-based ART regimens. Implications The etonogestrel implant remains a highly effective contraceptive option for women living with HIV who use dolutegravir-based ART.

Objective We aimed to compare rates of positive postpartum depression screens at 6 weeks postpartum among adolescents and young adults (AYA) initiating immediate postpartum contraceptive implants and those initiating other methods. Design Through a retrospective observational design, we collected data on demographics, reproductive history, prenatal and postnatal depression, and postpartum contraception. Setting Patients participating in an AYA prenatal-postnatal program were eligible for inclusion. Participants A total of 497 patients were enrolled between January 2013 and December 2016. The median age was 19 years (range 13-22 years); 86% were primiparous, 50% were Latina, 24% were black, and 16% were white; 34% initiated immediate postpartum implants (n = 169). Intervention Those initiating a contraceptive implant within the first 14 days postpartum were included in the intervention group. Main Outcome Measure We compared rates of positive Edinburgh Postpartum Depression Scales (EDPS) (scores ≥10) in AYA initiating immediate postpartum implants and those initiating other contraceptive methods. Results The AYA initiating immediate postpartum implants were similar to the rest of the cohort in baseline characteristics, aside from an increased rate of preterm births among the intervention group (19.4% vs 12.1%; P = .03). Prenatally, 14% had an elevated Center for Epidemiologic Studies Depression Scale (CES-D) scores (11.5% immediate postpartum implants vs 15.4% comparison, P = .25). At 6 weeks postpartum, 7.6% had a positive postpartum depression screen; this rate was significantly lower for those initiating immediate postpartum implants compared to those choosing other methods (4.1% vs 9.5%, P = .04). Conclusions Providers should continue to encourage AYA to choose whichever highly effective contraceptive method they prefer for postpartum use.

Objective To identify genetic variants associated with weight gain related to etonogestrel contraceptive implant use. Study design We conducted a retrospective analysis from a parent pharmacogenomic study of healthy, reproductive-aged women using etonogestrel implants. We reviewed medical records to calculate objective weight changes from implant insertion to study enrollment and asked participants about subjective weight gain (yes/no) during contraceptive implant use. We used genotyping data (99 genetic variants) from the parent study to conduct backward-stepwise generalized linear modeling to identify genetic variants associated with objective weight changes. Results Among 276 ethnically diverse participants, median body-mass index (BMI) was 25.8 kg/m2 (range 18.5–48.1). We found a median weight change of +3.2 kg (range −27.6 to +26.5) from implant insertion to study enrollment. Report of subjective weight gain had minimal agreement with measured weight gain during implant use (Cohen’s kappa = 0.21). Our final generalized linear model contained two variables associated with objective weight change that met conservative statistical significance (p Conclusion Genetic variants in the estrogen receptor 1 (ESR1) do not have known associations with obesity or metabolic syndrome, but there is physiologic plausibility for a progestin-mediated genetic association between ESR1 and weight gain. Additional genetic research is needed to substantiate our findings and elucidate further advances in individualized counseling on the risk of weight gain with exogenous steroid hormones. Implications Genetic variation in the estrogen receptor 1 gene may account for variability in weight gain among etonogestrel contraceptive implant users. If these findings can be replicated with other progestin-containing medications, we may be able to better individualize contraceptive counseling.

Background: Pelvic pain has been associated with Essure, a permanent contraceptive implant. Here we describe histopathologic findings in long-term Essure users with chronic pelvic pain. Methods: We descriptively evaluated and compared histopathologic features of hysterectomy specimens removed for a primary diagnosis of chronic pelvic pain from women with (n = 3) and without (n = 3) prior placement of Essure coils (mean of 8.6 years prior). Results: Interstitial fallopian tubes of Essure patients demonstrated fibrosis. Two cases had flattening of ampullary epithelial folds. Tubes of Essure users showed no acute inflammation, but 2/3 showed focal chronic inflammation. All patients had additional findings, such as endometriosis, adenomyosis or leiomyomas, that could be associated with pain. Conclusions: Given the minimal and bland inflammation in Essure cases, symptoms may more plausibly be ascribed to confounding gynecologic conditions or other mechanisms.

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

Background Contraceptive implants were introduced to Papua New Guinea (PNG) in 2012 but there is little data outlining the clinical efficacy and cultural acceptability of implants within a local population in rural PNG, and the impact that the introduction of implants has had on maternal health in these settings. We set out to explore these outcomes among a large, rural community on Karkar Island, PNG. Methods Paper I summarises the major trends in contraceptive use throughout PNG between 1996 and 2016. Paper II uses a cross-sectional survey design to determine continuation rates, satisfaction scores, side effects and failure rates associated with the implants at 12 months of use. Paper III uses time-series regressional analyses to assess the change in the rate of severe haemorrhage, sepsis, hospital readmission, low birth weight, prematurity and death before and after introduction of the implant on Karkar Island. Paper IV uses qualitative interviews to explore the pathways to decision-making around implant use on Karkar Island. Results Paper I demonstrates that the national unmet need for contraception in PNG remains high (32%) even after targeted introduction of the contraceptive implant. Paper II confirms high continuation rates with the implant (97%) with only 2% of women experiencing bothersome side effects. Paper III demonstrated at least a 56% and upto a 74% reduction in the rate of adverse birth outcomes following introduction of the implants. Paper IV revealed that men are supportive of their wives using family planning, but that there is a community-wide lack of familiarity with the contraceptive implant that lowers its uptake. Conclusions Our findings support the expansion of implants throughout rural PNG. Twelve-month follow-up data confirm high levels of uptake and community acceptability of the implant. However, our qualitative findings point to the need for ongoing community education as being critical to sustaining implant uptake in the future.

Background Kinshasa is Africa's third largest city and one of the continent’s most rapidly growing urban areas. PMA2020 data showed that Kinshasa has a modern contraceptive prevalence of 26.5% among married women in 2018. In Kinshasa’s method mix, the contraceptive implant recently became the dominant method among contraceptive users married and in union. This study provides insight into patterns of implant use in a high-fertility setting by evaluating the 24-month continuation rate for Implanon NXT and identifying the characteristics associated with discontinuation. Methodology This community-based, prospective cohort study followed 531 Implanon users aged 18–49 years at 6, 12 and 24 months. The following information was collected: socio-demographic characteristics, Method Information Index (MII) and contraceptive history. The main outcome variable for this study was implant discontinuation. The incidence rate of discontinuation is presented as events per 1000 person/months (p-m), from the date of enrolment. The Cox proportional hazards modelling was used to measure predictors of discontinuation. Results A total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95% CI: 9.04–9.08) removals per 1000 p-m. Of nine possible co-variates tested, the likelihood of discontinuation was higher among women who lived in military camps, had less than three children, never used injectables or implants in the past, had experienced heavy/prolonged bleeding, and whose MII score was less than 3. Conclusion In addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns.

Objectives: Our primary objective was to compare geometric mean levonorgestrel concentrations between levonorgestrel implant users who were or were not taking the antiretroviral efavirenz, for up to 30 months after implant initiation. Our secondary objective was to evaluate the pregnancy rate among levonorgestrel implant users on efavirenz. Study design: We performed a subanalysis of 42 Malawian women randomized to initiate the levonorgestrel implant as part of a parent randomized clinical trial. Our subset included 30 HIV-infected women taking efavirenz and 12 HIV-uninfected women not taking efavirenz. They underwent urine pregnancy testing every 3 months and serum levonorgestrel testing at day 3 and months 1, 3, 6, 12, 18, 24, 27 and 30 after implant initiation. Geometric mean levonorgestrel concentrations were calculated for efavirenz users and non-efavirenz users at each time point. Results: The geometric mean levonorgestrel concentrations were lower for efavirenz users than non-efavirenz users at every time point; the geometric mean ratio for efavirenz users:non-efavirenz users ranged from 0.60 [90% confidence interval (CI) 0.46–0.79] at 1 month to 0.27 (90% CI 0.12–0.61) at 30 months after implant insertion. No pregnancies occurred over 60 woman-years of concomitant levonorgestrel implant and efavirenz use, although 11 women had levonorgestrel concentrations

International audience; 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.

Background According to the United Nations Trends in Contraceptive Use 2015 report, at least one in ten married or in-union women in most regions of the world has an unmet need for family planning. Family Planning 2020 reports an estimate of almost 134 million married or in-union women of reproductive age who have an unmet need for modern methods of contraception in 2016 in participating countries. Family planning has therefore been highlighted as a global unmet need. Initiatives such as Family Planning 2020 aim to promote contraceptive use through Implanon® contraceptive implant. Implanon® has been reported to be a highly effective form of contraception. However, poor outcomes from users of the Implanon® have been reported in recent studies. The main objective of this review is to map the literature for the evidence on usage of Implanon® in order to reveal challenges and barriers. Methods and analysis A scoping review searching evidence on Implanon® use will be conducted. Relevant studies will be identified from 1998 to present. The following databases: PubMed, MEDLINE, EBSCOhost, Google Scholar and Cochrane library will be searched for peer-reviewed literature. We will also search for grey literature in this study area. The eligibility criteria will guide the study selection. A data charting table will be designed to extract information from the literature. The results of this study will be reported by use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Data will be analysed using thematic analysis and the NVIVO software version 10. The mixed method appraisal tool (MMAT) will be used to assess the quality of included studies. Discussion We anticipate finding relevant studies on the use of Implanon®. Evidence gathered from included studies will help us identify gaps in research and help guide future research on Implanon® usage. This information can also help guide implementers and users on challenges and barriers related to use of Implanon®. Systematic review registration PROSPERO CRD42017072926.

To assess the impact of contraceptive counseling on the uptake of long-acting reversible contraception (LARC), namely, intrauterine devices and the contraceptive implant, by 3 months postpartum among women with a recent preterm birth.We enrolled patients in a single-blinded, one-to-one, randomized, controlled trial to assess the impact of enhanced family planning counseling immediately after a viable preterm birth in the inpatient setting. Participants received either structured counseling with an emphasis on LARC by a family planning specialist (intervention) or routine postpartum care (control). We followed participants to the primary outcome of LARC use 3 months postpartum.We followed 121 participants for 3 months. Primary outcome data were available for 119 participants (61 intervention, 58 control). We found no demographic differences between the groups. Participants in the intervention group were significantly more likely to use LARC at 3 months postpartum compared with controls (51% vs. 31%; p .05). For every six women who received the counseling intervention, one additional woman was using a LARC method at 3 months.After a preterm birth, brief LARC-focused, structured counseling before hospital discharge significantly increased LARC method use at 3 months postpartum.

Introduction Contraceptives improve women's lives and public health, but many women discontinue their contraceptive method owing to dissatisfaction. An underexamined aspect of contraceptive discontinuation is sexual acceptability, or how contraception affects sexual experiences. Investigators' aims were two-fold: 1) to document changes in multiple domains of women's sexual experiences with their intrauterine device (IUD) or contraceptive implant over time and 2) to examine whether these sexuality factors were associated with method continuation at 12 months. Methods We enrolled 200 eligible family planning clients and collected data at baseline and at 1, 3, 6, and 12 months. Sexual acceptability measures included the Female Sexual Function Index-6, the New Sexual Satisfaction Scale, and participants’ perceptions of whether their contraceptive method had had a neutral, positive, or negative effect on their sex life. Survival analysis and Cox regression with time-varying covariates related sexuality measures to method continuation over time while controlling for other relevant factors. Results Among 193 women who received an IUD or implant, 20% selected the copper IUD, 46% the levonorgestrel IUD, and 34% the etonogestrel implant. Ten percent discontinued their method during the year. Although changes in Female Sexual Function Index-6 and New Sexual Satisfaction Scale scores were not associated with discontinuation, individuals who perceived that their method detracted from their sexual experience had significantly higher removal rates than those who reported no sexual changes or positive sexual changes (adjusted hazard ratio, 8.04; 95% CI, 1.53–42.24), even when controlling for method type, bleeding changes, and a variety of covariates and controls. Conclusions Although limited by the small sample of discontinuers, we found that women's perceptions of how their method affects their sex life were associated with contraceptive continuation over time. Sexual acceptability should receive more attention in both contraceptive research and counseling.

The etonogestrel subdermal contraceptive implant (EI), NexplanonⓇ, is a sterile 4-cm × 2-mm single rod that is implanted subdermally in a woman’s upper arm and can provide up to 3 years of continuous highly effective contraception (failure rate 0.05%). NexplanonⓇ prevents pregnancies primarily by inhibiting ovulation and secondarily by increasing cervical mucus viscosity and causing alterations in the endometrium. The most common side effect is changes in menstrual bleeding patterns. NexplanonⓇ (FDA-approved 2011) replaced the original etonogestrel subdermal contraceptive implant, ImplanonⓇ (FDA-approved 2006), due to cases of incorrect insertions with the ImplanonⓇ applicator device. Each NexplanonⓇ rod contains 68 mg of the progestin etonogestrel and 15 mg of barium sulfate (to facilitate localization via X-ray), encased in an ethylene vinyl acetate copolymer core and rate-controlling membrane. It is supplied in a sterile, preloaded disposable applicator that prevents noninsertion, greatly facilitates proper insertion in a superficial plane, reduces the risk of infection via contamination of the sterile rod, and allows insertion without the need for incision and concomitant risk of scarring. All physicians and advanced practice clinicians should participate in the FDA-mandated 2-hr live NexplanonⓇ Clinical Training Program to certify their ability to properly insert, localize, and remove the etonogestrel implant prior to performing these procedures on patients.

The etonogestrel contraceptive implant is a radiopaque rod inserted into the subcutaneous tissue of the upper arm which should be palpable and easily removed. Intravascular migration of a contraceptive subcutaneous implant is referred in the literature but is considered a rare complication.[1][1]

Introduction Women's roles continue to increase within the U.S. Army. Medical readiness contributes to individual readiness and supports the Army's warfighting mission. Army physician assistants are often the first-line medical providers for Soldiers and their practices, including women's health practices, should support optimal Soldier readiness. Our objective was to survey Army physician assistants' knowledge and practices related to female reproductive health care. Materials and methods This was a descriptive survey-based study of Army physician assistants conducted from February to June 2017. This study was an addendum to a prior study examining women's health care knowledge and skills among physicians serving as general medical officers. Surveys were distributed via e-mail. The survey was anonymous and included 22 questions describing provider knowledge and practices in the areas of family planning and women's health screening. Results Out of 198 distributed surveys, 100 (51%) were returned. Most respondents were male (67%), 75% practiced in a troop-based medical clinic, and 73% had current or past practice experience in a military operational/deployed environment. The majority of respondents indicated that they provide family planning services to their reproductive-aged female patients. Combined hormonal contraceptives and depo-medroxyprogesterone had the highest percentage of respondents who reported comfort discussing the method. The highest percentage of respondents indicated discomfort discussing the copper intrauterine device and emergency contraception. Only 10, 17, and 33% of respondents were trained to place the copper intrauterine device, levonorgestrel intrauterine device, and etonogestrel contraceptive implant, respectively. Most respondents offered cervical cancer (74%) and chlamydia (91%) screening to their female patients. Conclusion Most study respondents practiced in a troop-based primary care clinic and most reported experience as a deployed health care providers. Although most respondents indicated comfort discussing combined hormonal contraception and depo medroxyprogesterone, fewer reported comfort discussing long-acting reversible and emergency contraception. Only a minority of respondents reported prior training to place the copper or levonorgestrel intrauterine device or contraceptive implant and, of those trained, most had not placed a device for which they were trained in the preceding 12 months. Chlamydia and cervical cancer screening were offered by most respondents but was not universally offered among the respondents. These findings are consistent with our previous study evaluating women's health knowledge among general medical officers and highlight a need for improved training in the field of women's health for physician assistants serving the active duty population.

BackgroundOf the 70 000 people experiencing homelessness in Scotland, at least 40% are women. Little is known about their contraceptive usage. Most pregnancies in homelessness are unintended and children are usually looked after in the care system.MethodsA case note review of women’s current contraceptive usage in a primary care service serving women experiencing homelessness in Edinburgh, Scotland. The service electronic database was searched for keywords relating to contraception to determine current usage, but also reproductive health, wider demographics and previous pregnancies.ResultsOf 174 women (16–55 years), 75 (43%) were recorded as using a contraceptive method. 49 (28%) were using long-acting reversible contraception (LARC), most of which was the contraceptive implant. However, 6/41 (15%) of the most effective LARC (intrauterine contraception and implant) was being used beyond its’ expiry date. 34 (20%) had no mention of contraceptive use in their medical record and 32 (19%) were not using contraception despite being sexually active. 6 (3%) had been hysterectomised/female sterilisation. 26 (15%) were not sexually active. 179 of the 233 (77%) children mentioned in women’s electronic records were recorded as being looked after out with their care. 138/174 (79%) had current/previous drug or alcohol misuse. 100/174 (57%) had a history of domestic violence or abuse. 22/174 (13%) were involved/had been involved in sex work.ConclusionsPrimary care services need to give greater attention to the contraceptive needs of homeless women to empower them to become pregnant when the time is right for them and prevent the consequences of unintended pregnancy and homelessness.

This study aimed to investigate the efficacy of the etonogestrel (ENG)-releasing implant in treating patients with rectovaginal endometriosis. The study was based on the retrospective analysis of a prospectively collected database, including symptomatic women who had ultrasonographic diagnosis of rectovaginal endometriosis. Patients were follow-up at 6, 12 and 24 months from the insertion of the ENG-releasing implant. The intensity of pain symptoms was evaluated using a visual analog scale. The volume of the nodules was estimated by virtual organ computer-aided analysis. The Endometriosis Health Profile (EHP-30) was used to evaluate quality of life. Overall, 43 women were included in the study. The 2-year continuation rate for the ENG-releasing implant was 93.0%. The treatment quickly improved the intensity of non-menstrual pelvic pain, deep dyspareunia, dysmenorrhea, and dyschezia. At 6-month follow-up, there were improvements in all domains of the EHP-30 compared with baseline. Further improvements in the EHP-30 results were observed only in pain sub score at 12-month follow-up and in emotional well-being sub score at 24-month follow-up. At 6-month follow-up the volume of the rectovaginal nodules was significantly lower compared with baseline; a further decrease was observed at 12- and 24-month follow-up. The treatment was well tolerated.

To compare long-acting reversible contraceptive (LARC) uptake before and after the Affordable Care Act (ACA) contraceptive mandate among women undergoing a first trimester surgical abortion.We conducted a retrospective chart review of 867 women undergoing a first trimester surgical abortion at an academic gynecology practice between December 2010 and December 2014 (excluding August to December 2012) to evaluate intrauterine device and contraceptive implant uptake before and after the ACA contraceptive mandate.Before the ACA contraceptive mandate, 79% of privately insured women (213 of 271) had full LARC coverage (no out-of-pocket costs) compared with 92% (298 of 324) after the mandate (p .001). We found no difference in postabortal LARC uptake before and after the ACA in women with private insurance, Medicaid, or overall. Among all women, 46% chose a postabortal LARC method before the mandate as compared with 48% after the mandate (p = .63). Among privately insured women, 45% used a postabortal LARC method before the mandate as compared with 50% after the mandate (p = .25). One-half of privately insured women (268 of 534) with full or partial LARC coverage used a postabortal LARC method compared with 32% of privately insured women (18 of 56) with no LARC coverage after implementation of the ACA contraceptive mandate (p = .01).Despite the significant increase in full coverage of LARC among privately insured women, there was no change in postabortal LARC use after the ACA. However, privately insured women with full or partial LARC coverage were more likely to use a postabortal LARC method compared with privately insured women with no LARC coverage after the implementation of the ACA contraceptive mandate.

OBJECTIVE To compare the 6-month use rate of the etonogestrel implant placed immediately after dilation and evacuation (D&E) with placement 2-4 weeks postprocedure. METHODS This is a randomized controlled trial of women seeking abortion between 14 0/7 and 23 5/7 weeks of gestation and desiring the etonogestrel contraceptive implant at an urban family planning clinic. Participants were randomized to device insertion immediately after the D&E compared with delayed insertion in 2-4 weeks. The primary outcome was implant use rate at 6 months after insertion and was determined by follow-up phone interviews. Secondary outcomes included repeat pregnancy rates and method satisfaction. The sample size of 120 participants was calculated based on a power of 0.80 to demonstrate a 20% difference in implant use rates between groups assuming 40% of women overall are not using the device 6 months after the procedure. RESULTS Between November 2015 and October 2016, 148 participants were enrolled. Seventy-three participants (49.3%) were randomized to and underwent immediate implant insertion after D&E. The remaining 75 (50.6%) were randomized to delayed insertion. There were no significant differences in sociodemographic characteristics between the groups. Placement rate was 100% in the immediate group compared with 42.7% in the delayed group (P