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The introduction of contraception has significantly improved lifestyle choices for women. The majority of women go to their general practice for contraception, and therefore, GPs have an important role in helping to guide their decision-making. The progesterone-only implant is one of the four available long-acting methods of contraception; it works mainly by preventing ovulation. It is a small 40-mm rod that is implanted into the subdermal tissue in the upper arm, where it provides contraception for up to 3 years. It is both one of the most reliable methods of contraception and is more cost-effective than traditional methods.

To ascertain whether placement of the etonogestrel contraceptive implant induces significant changes in carbohydrate and lipid metabolism, as reflected by metabolic parameters, in healthy women.Prospective cohort study of 213 healthy patients who received etonogestrel implants. Weight, BMI, blood pressure and a comprehensive metabolic profile were assessed at baseline, 1, 2 and 3 years. In 21 of the 213 participants, AUC for glucose levels, fasting insulin levels at baseline and year 3 (immediately before implant removal), HOMA-IR score, and the QUICK index were assessed. Parameters were expressed as median and interquartile range. The Wilcoxon test and ANOVA were used for comparison of measurements after implant placement (significance level p0.05).Median age was 26 years (range, 22-31.5). Results showed a trend toward increase of the variables weight (63.3-66.1) and BMI (24.7-25.7) and a decrease in TC (172-161.5), TG (75-69.5), and LDL (100.5-98.5) (p0.05). Of the metabolic variables, FBG (85-88) and HDL (53-46) had significant differences (p0.002). In the subgroup of 21 patients, there were reductions in insulin levels (9.65 vs. 8.4mU/dL, p=0.03), HOMA scores (2.06 vs. 1.75, p=0.02), QUICK index (0.34 vs. 0.35, p=0.03), TC (178 vs. 160mg/dL, p=0.001), HDL (51 vs. 46mg/dL, p=0.009), and LDL (110 vs. 100mg/dL, p=0.035).These results provide evidence of the metabolic safety of the ENG implant in healthy women over a 3-year period. Indeed, implant placement induces changes consistent with a lower risk of insulin resistance and dyslipidemia.

Objective The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation. Study design A retrospective chart review identified adolescent females aged 12 to 22years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12months) and ENG continuers (continued for ≥12months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ 2 /Fisher's Exact Tests and backwards stepwise logistic regression. Results Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12months of use. The mean length of implant use for those who discontinued was 7.5months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥1 medical visit for implant concerns (not including removal) were independently predictive (p Conclusion The vast majority of adolescents continued the ENG implant at 12months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers. Implications The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting.

Significant public health disparities exist surrounding teen and unplanned pregnancy in the United States. Women of color and those with lower education and socioeconomic status are at much greater risk of unplanned pregnancy and the resulting adverse outcomes. Unplanned pregnancies reduce educational and career opportunities and may contribute to socioeconomic deprivation and widening income disparities. Long-acting reversible contraception (LARC), including intrauterine devices and implants, offer the opportunity to change the default from drifting into parenthood to planned conception. LARC methods are forgettable; once placed, they offer highly effective, long-term pregnancy prevention. Increasing evidence in the medical literature demonstrates the population benefits of use of these methods. However, barriers to more widespread use of LARC methods persist and include educational, access, and cost barriers. With increasing insurance coverage under the Affordable Care Act and more widespread, no-cost coverage of methods, more and more women are choosing intrauterine devices and the contraceptive implant. Increasing the use of highly effective contraceptive methods may provide one solution to the persistent problem of the health disparities of unplanned and teen pregnancies in the United States and improve women's and children's health.

Objective Ethiopia is home to an increasingly large refugee population. Reproductive health care is a critical issue for these groups because refugee women are at high risk for unmet family planning needs. Efforts to expand contraceptive use, particularly long acting reversible contraceptive (LARC) methods are currently underway in several Ethiopian refugee camps. Despite availability of LARC methods, few refugee women opt to use them. The purpose of this study was to explore how culture influences contraceptive attitudes and behaviors, particularly towards LARC methods, among Ethiopia's refugee populations. Methods Focus group discussions and individual interviews were conducted with Eritrean and Somali refugees living in Ethiopia. The qualitative data was analyzed to identify important themes highlighting the relationship between cultural values and contraceptive attitudes and behaviors. Results Childbearing was highly valued among participants in both study groups. Eritreans reported desire to limit family size and attributed this to constraints related to refugee status. Somalis used cultural and religious faith to deal with economic scarcity and were less likely to feel the need to adapt contraceptive behaviors to reduce family size. Participants held overall positive views of the contraceptive implant. Attitudes toward the intrauterine device (IUD) were overwhelmingly negative due to its long-acting nature. Conclusions Culture, religion and refugee status form a complex interplay with family planning attitudes and behaviors among Eritrean and Somali refugees. For these populations, the three-year implant appears to be a more acceptable contraceptive method than the longer-acting IUD because it is in line with their reproductive plans.

Studies have not found that hormonal contraceptive implants adversely affect breastfeeding, but theoretical concerns exist.We reported a case of reduced weight gain in an exclusively breastfed infant in association with placement of (ENG)-releasing contraceptive implant (Nexplanon) to the FDA Adverse Events Reporting System (FAERS). We further queried reports to FAERS and reviewed published studies of the ENG implant during breastfeeding.A breastfeeding mother received an ENG implant at 4 weeks postpartum. Her infant was exclusively breastfeeding. One month after implant placement, the infant had lost 145 g, dropping from the 44th percentile to the 6th percentile for growth. During this period, the mother had not returned to work or decreased frequency of feeding. During a 2-year period of FAERS reports, we found one other report of reduced milk supply following ENG implant placement. Among 108 breastfeeding women studied while using the ENG implant, there was one case of lactation failure. If this were not due to chance, the estimated risk of lactation failure with the ENG implant would be 0.9% (95% confidence interval 0.2-5.1%).Given uncertainty regarding the true effect of ENG implants on lactation, it seems prudent for providers to counsel each woman about a possible effect on milk supply so that she can monitor her infant for signs of impaired milk transfer. Patient-centered counseling approaches are needed that allow each woman to assess her own individual tolerance of risk of unplanned pregnancy versus possible risk of lactation failure.

The effectiveness of Tenofovir based HIV pre-exposure prophylaxis (PrEP) is proven, but hinges on correct and consistent use. User compliance and therapeutic effectiveness can be improved by long acting drug delivery systems. Here we describe a thin-film polymer device (TFPD) as a biodegradable subcutaneous implant for PrEP.A thin-film polycaprolactone (PCL) membrane controls drug release from a reservoir. To achieve membrane controlled release, TAF requires a formulation excipient such as PEG300 to increase the dissolution rate and reservoir solubility. Short-term In vitro release studies are used to develop an empirical design model, which is applied to the production of in vitro prototype devices demonstrating up to 90-days of linear release and TAF chemical stability.The size and shape of the TFPD are tunable, achieving release rates ranging from 0.5 to 4.4 mg/day in devices no larger than a contraceptive implant. Based on published data for oral TAF, subcutaneous constant-rate release for HIV PrEP is estimated at2.8 mg/day. Prototype devices demonstrated linear release at 1.2 mg/day for up to 90 days and at 2.2 mg/day for up to 60 days.We present a biodegradable TFPD for subcutaneous delivery of TAF for HIV PrEP. The size, shape and release rate of the device are tunable over a8-fold range.

Purpose To describe changes in receipt of immediate postabortion long-acting reversible contraception (LARC) by adolescent and nulliparous women in New Zealand. Methods Nationally collected data on immediate postabortion receipt of an intrauterine method (intrauterine device [IUD]/intrauterine system [IUS]) or contraceptive implant were analyzed to describe proportions and demographic characteristics of women receiving LARC between 2007 and 2013. Changes in uptake over time were presented for adolescent, nulliparous, and parous women. Results Postabortion LARC uptake increased between 2007 and 2013, rising from 7.9% to 42.7% for adolescents and from 8.8% to 36.9% for nulliparous women. The increase was highest among nulliparous adolescents with a seven-fold increase in LARC uptake between 2007 and 2013. Adolescents had a five-fold increase and nulliparous women (of all ages) a four-fold increase. In 2013, IUD/IUS use was lowest among adolescents (22.4%) and increased with increasing age (43% by ages 40+ years), whereas implant use was highest among adolescents (20.3%) and decreased with increasing age (to 4.6% by age 40+ years). Nulliparous women had the lowest use of both IUD/IUS and implants in 2013, with 24.6% receiving an intrauterine method (compared with 43.2% for para 3+), and 12.3% an implant (compared with 17.5% for para 3+). Conclusions Despite an overall trend toward increased uptake of postabortion LARC by adolescent and nulliparous women, uptake in these groups still lags behind that of parous and older women. Reasons for differential uptake need to be explored and addressed if necessary to ensure all women have equitable access to the most effective methods of contraception.

Background Repeat termination of pregnancy highlights the issues of unplanned pregnancies and effective post-termination contraceptive practices. Objective To examine the risk factors at the time of a first termination that are associated with subsequent repeat termination. Design Registry-based study. Setting Grampian region of Scotland, UK. Methods A retrospective study using data from the Termination of Pregnancy Database, NHS Grampian for the period 1997–2013. Associations between repeat termination and women9s sociodemographic characteristics and contraceptive use were assessed using multivariable logistic regression models. Results This study showed that 23.4% of women who had an initial termination ( n =13 621) underwent a repeat termination. Women who had repeat terminations were more likely to be aged under 20 years at their initial termination with an adjusted odds ratio (AOR) of 5.59 [95% confidence interval (CI) 4.17–7.49], to belong to the most deprived social quintile [AOR 1.23 (95% CI 1.05–1.43)], and to be more likely to have had two or more previous livebirths [AOR 1.51 (95% CI 1.12–2.02)] or miscarriages [AOR 1.40 (95% CI 1.02–1.92)]. The likelihood of having a repeat termination was increased in women who had a contraceptive implant as post-termination contraception [AOR 1.78 (95% CI 1.50–2.11)] compared to women who left with none or unknown methods following the first termination. In those who had repeat terminations, women who had an implant or Depo-Provera ® were at increased odds of repeat termination in the 2–5 years interval compared to the 0–2 years after their initial termination. Conclusions Teenage pregnancy, social deprivation, two or more previous livebirths or miscarriages at the time of the initial termination were identified as risk factors for repeat terminations. Post-termination contraception with implants and Depo-Provera® were associated with repeat termination 2–5 years after the first termination.

Women receiving efavirenz-based antiretroviral therapy plus a contraceptive implant had significantly lower levonorgestrel pharmacokinetics than women not receiving antiretroviral therapy. An unexpected high pregnancy rate (3/20, 15%) occurred in the efavirenz group, highlighting the clinical significance of this interaction., Background. Levonorgestrel subdermal implants are preferred contraceptives with an expected failure rate of

Medical abortion using mifepristone and misoprostol comprises a growing proportion of abortions performed in the United States. Simplifying the process of medical abortion can optimize use of resources and improve care for women.Medical abortion using evidence-based protocols is effective through 70 days' gestation. The requirement of a follow-up office visit with a transvaginal ultrasound to ensure completion of medical abortion is safely and effectively replaced with self-administered low-sensitivity or semiquantitative urine pregnancy tests and remote communication with women. Most contraceptive options can be initiated the same day as mifepristone administration to improve contraceptive use after medical abortion. State legislatures continue to pass laws that threaten evidence-based medical abortion practices. Such efforts ultimately limit access to well-tolerated and effective medical abortion services.Research supports simplification of the follow-up protocol for medical abortion, and provision of the contraceptive implant and progestin injectable for postabortion contraception the same day as mifepristone administration. With disregard to its documented safety and efficacy, legislative challenges persist as significant challenges to provision of evidence-based medical abortion.

Objective To evaluate whether initiation of a contraceptive implant, a method of long-acting reversible contraception, reduces condom use, as measured by a biomarker of recent semen exposure [prostate-specific antigen (PSA)]. Study design We conducted a randomized controlled clinical trial in which 414 Jamaican women at high risk for sexually transmitted infections (STIs) attending family planning clinics received the contraceptive implant at baseline (“immediate” insertion arm, N = 208) or at the end (“delayed” insertion arm, N = 206) of a 3-month study period. Participants were tested for PSA at baseline and two follow-up study visits and were asked about their sexual activity and condom use. Results At baseline, 24.9% of women tested positive for PSA. At both follow-up visits, the prevalence of PSA detection did not significantly differ between the immediate versus delayed insertion arm [1-month: 26.1% vs. 20.2%, prevalence ratio (PR)=1.3, 95% confidence interval (CI)=0.9–1.9; 3-month: 25.6% vs. 23.1%, PR = 1.1, 95% CI=0.8–1.6]. The change in PSA positivity over the three study visits was not significantly larger in the immediate arm compared to the delayed arm (1-sided p-value of .15). Conclusions Contraceptive implants can be successfully introduced into a population at high risk of unintended pregnancy and STIs without a biologically detectable difference in unprotected sex in the short term. This information strengthens the evidence to support promotion of implants in such populations and can help refine counseling for promoting and maintaining use of condoms among women who choose to use implants. Implications Sex unprotected by a condom was not higher over 3 months in women receiving a contraceptive implant, compared with those not receiving the implant.

Long-acting reversible contraception (LARC) is the most effective form of reversible contraception. Although most women are satisfied with LARC methods, unscheduled bleeding and spotting are common reasons for method dissatisfaction and discontinuation. This systematic analysis of the current literature delineates treatment options for unscheduled bleeding related to LARC use. Although consistent results are lacking, all devices seem to have the best response to nonsteroidal antiinflammatory drugs for 5 to 7 days or the antifibrinolytic agent tranexamic acid. Additional studies are necessary to identify improved treatment interventions for unscheduled bleeding with LARC use.

Adolescents have high rates of unintended pregnancy and face unique reproductive health challenges. Providing confidential contraceptive services to adolescents is important in reducing the rate of unintended pregnancy. Long-acting contraception such as the intrauterine device and contraceptive implant are recommended as first-line contraceptives for adolescents because they are highly effective with few side effects. The use of barrier methods to prevent sexually transmitted infections should be encouraged. Adolescents have limited knowledge of reproductive health and contraceptive options, and their sources of information are often unreliable. Access to contraception is available through a variety of resources that continue to expand.

Despite the availability of a variety of contraceptive methods, millions of women still have an unmet need for contraceptive choices. Short-acting methods are plagued by issues with adherence, leading to imperfect or inconsistent use and subsequent unintended pregnancy. Long-acting contraceptive methods such as intrauterine devices and contraceptive implants, while providing highly effective and safe contraception, do not meet the needs of all women, often due to cost, access or acceptability issues. Several new methods are in various stages of development and are designed to address the shortcomings of current methods. Providers should be aware of these future options and how they might better meet women's needs.

The etonogestrel contraceptive implant is a 4-cm radio-opaque subdermal rod, inserted in the nondominant arm, providing up to 3 years of continuous contraception. We describe a 21-year-old nulligravid, nondepressed female who experienced new-onset secondary anorgasmia 1 month after etonogestrel insertion. Off-label, oral use of bupropion and sildenafil did not restore orgasmic ability. Finally, 1 week after implant removal (4½ months after insertion), spontaneous return of orgasmic ability occurred. Anorgasmia after etonogestrel implant use is a rare adverse event; nonetheless, clinicians should be alert to its possibility. Implication statement This report documents secondary anorgasmia in a nondepressed female temporally associated with etonogestrel implant insertion. Clinicians should be aware that this rare event can occur but is quickly reversible with implant removal.

An 18-year-old woman had an etonogestrel implant inserted into her left upper arm 2 years earlier for menorrhagia. Her symptoms were not well controlled and she requested the implant to be removed. However, clinicians were unable to locate the implant on her left arm. Computed tomography showed that the implant had migrated to a sub-lobar branch of the left lower lobe pulmonary artery. The long-term effect of leaving an etonogestrel implant in the pulmonary arterial system is unknown. This report adds to the small body of evidence on intravascular migration of a subdermally placed contraceptive implant.

Subdermal implantable devices are commonly used for long-acting contraception in the United States and Europe. Although relatively safe in nature, their implantation and removal may be associated with potential complications, some of which may require surgical intervention. Complications may include infection, incorrect implantation, migration, or difficulty with removal. Proximal migration has been reported; however, there are no reports of devices that have migrated within the brachial neurovascular sheath. This case report describes migration of an implantable contraceptive within the brachial neurovascular sheath that required surgical removal.

Women receiving implant insertion at the community level were significantly more likely to report keeping their implant for more than 3 years. Even when a referral or back-up system for removals existed, efforts to task-shift the provision of contraceptive implants may have inadvertently led to extended implant use., Key Findings Women receiving implant insertion at the community level were significantly more likely to report keeping their implant for more than 3 years.Task sharing only implant insertion and not removal services to community-based health worker cadres may have inadvertently led to extended implant use, particularly in rural areas or areas far from facilities. Key Implications Governments and program planners should prioritize efforts to ensure that implant removal services are available at the same health system level as insertions.National stakeholders and implementing partners should consider including implant removal as part of the training for all health care providers who are trained in insertion., Background: In 2009, the Government of Ethiopia initiated the implant scale-up initiative, which expanded contraceptive access by training health extension workers (HEWs) to insert single-rod etonogestrel contraceptive implants (Implanon) at rural health posts. Removals were provided by referrals to higher levels of the health system. However, little was known about whether women were getting their implants removed at the recommended 3-year postinsertion date or what barriers they faced to removal. Methods: Between June and July 2016, 1,860 Ethiopian women, who had a 1-rod etonogestrel implant inserted by either an HEW or another health care provider between 3 and 6 years prior, were surveyed. We describe the characteristics of the sample and use multivariable logistic regression to predict factors associated with keeping implants inserted beyond 3 years. Results: Women who had received their implants from HEWs were significantly more likely to report keeping them inserted for more than 3 years (adjusted odds ratio=2.50; 95% confidence interval=1.19, 5.24), compared with those who got their implant from another health care provider. Women who reported distance to the facility or transportation as a barrier were also significantly more likely to keep their implant for more than 3 years. Married and educated women were less likely to keep their implants for an extended duration. Among women who had their implant for 3 years or less, women who had had it inserted by an HEW were significantly more likely to report that the provider was unable or refused to provide removal as a barrier. Discussion: Efforts to expand lower level and community-based access to contraceptive implants that do not ensure reliable access to removals at the same level as insertions may lead to women using implants beyond the recommended duration.

The Long-Acting Reversible Contraception (LARC) Program at the American College of Obstetricians and Gynecologists (ACOG) celebrated its 10th anniversary in 2018. This Viewpoint article reviews opportunities, challenges, and lessons learned by the ACOG LARC Program throughout the last decade. Housed within the largest medical organization representing women’s health providers, the LARC Program supports change by developing resources for clinicians, healthcare systems, healthcare organizations, and policy makers. The Program’s Postpartum Contraceptive Access Initiative (PCAI) meets specific needs identified by an Expert Work Group using implementation science principles, including improved contraceptive counseling and clinician training, and institution-wide sustainable systems change in billing, coding, pharmacy, and electronic medical record integration. Key lessons learned include the importance of centering patient preferences and autonomy, developing foundational evidence-based guidance, supporting practice change through implementation tools and collaboration with local champions, advocating for insurance and payment policy, and partnering with other health care organizations to develop robust resources to improve patient access to the full range of contraceptive methods.

Introduction: In two high-volume government hospitals, their two affiliated health facilities, and two additional health facilities, we developed and implemented postpartum intrauterine device (PPIUD) and postpartum (PP) implant promotional counseling and service delivery procedures between May-July 2017 in Kigali, Rwanda. Between August 2017 and July 2018, 9,073 pregnant women received PPIUD/PP implant promotions who later delivered in one of our selected facilities. Of those, 2,633 had PPIUDs inserted, and 955 had PP implants inserted. The goal of the present analysis is to detail implementation expenditures and estimate incremental costs per insertion and couple years of protection (CYP) for PPIUD and PP implant users. Methods: We detail the incremental costs during the implementation from the health system perspective (including both the implementation costs and the cost of contraceptive methods) and use of standard methods to estimate the cost per insertion and CYP for PPIUD and PP implant users. In addition to the incremental costs of labor and supplies, the costs of promotional activities are included. Research costs for formative work were excluded. Results: A total of $74,147 USD was spent on the implementation between August 2017 and July 2018. The largest expense (34% of total expenses) went toward personnel, including doctoral-level, administrative, data management and nurse counseling staff. Training for PPIUD and implant providers and promoters comprised 8% of total expenses. Recruitment and reimbursements comprised 6% of expenses. Costs of implants to the government comprised 12% of the expenses, much higher than the cost of IUDs (1%). Costs per insertion were $25/PPIUDs and $77/PP implant. Costs per CYP were $6/PPIUDs and $21/PP implant. Conclusion: Understanding the cost per PPIUD/PP implant inserted and CYP can help to inform the cost of scaling up PPIUD/PP implant service implementation activities and resource allocation decision-making by the Rwandan Ministry of Health.

Introduction Nexplanon is a 4 cm rod-shaped barium sulphate coated contraceptive implant with a usual subdermal insertion in the inner non-dominant upper arm. Complications proper to subdermal contraceptive implants are unusual and principally localized and minor, comprising infection at the site of implantation, hematoma, abnormal scar development, or local nerve and blood vessel injuries. Infrequently, contraceptive implant migration can happen, though habitually not far from the site of insertion. Pulmonary embolization of the device is remarkably rare and can present with symptoms such as chest pain or dyspnea. Patient concerns and diagnosis We report one of the rare cases of asymptomatic Nexplanon pulmonary embolism in a 26-year-old female. Interventions and outcomes An endovascular intervention successfully retrieved the device from the lateral segment right middle lobe pulmonary artery without any complications. Conclusion Several cases of contraceptive implant migration into the pulmonary artery have been reported to this day. Preventing this life-threatening complication is challenging, and yet, no clear guidelines have been established.

Immune thrombocytopenic purpura (ITP) is an acquired disorder of platelets that clinically manifests with mucocutaneous bleeding. There areseveral causes of ITP, but its association with hormonal contraceptive implants has not been widely reported. A 39‑year‑old Para 10+0 7 alivepresented to the Yobe State University Teaching Hospital with complaints of nasal bleeding, gum bleeding, purpura, and menorrhagia, whichwere noticed a month after insertion of a Levonorgestrel – containing hormonal contraceptive implant, at a Primary Healthcare facility. Completeblood count, peripheral blood film, and bone marrow aspiration cytology led to the diagnosis of ITP. Epistaxis was managed conservatively.The patient was placed on prednisolone with a noticeable increase in platelet count and remarkable improvement in the clinical state. ITP is acomplication of the hormonal contraceptive implant. Clinicians should be aware of the possible association of contraceptive implants and ITP. Keywords: Hormonal contraceptive implants, immune thrombocytopenic purpura, mucocutaneous bleeding, prednisolone

The aim of the study was to assess the serum levels of the following biomarkers in women with endometriosis-associated pelvic pain before and after six months of using the etonogestrel (ENG) contraceptive implant or the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS): cancer antigen (CA)-125, cluster of differentiation (CD) 23 and endometrial nerve fibre density.The study was conducted at the Department of Obstetrics and Gynaecology, University of Campinas Medical School, Brazil. A total of 103 women with endometriosis-associated pain diagnosed by surgery, transvaginal ultrasound and/or magnetic resonance imaging were included. Endometrial nerve fibre density and serum levels of CA-125 and soluble CD23 were assessed before and after six months of using the allocated method and were correlated to 10 cm visual analogue scale (VAS) scores for non-cyclical pelvic pain and dysmenorrhoea.Both contraceptive methods significantly reduced concentrations of serum soluble CD23 and endometrial nerve fibre density (p .001); however, CA-125 was significantly reduced only among users of the ENG implant (p .05). No correlation was observed between reduction of biomarkers and improvement of VAS pain and dysmenorrhoea scores. No differences were observed between the ENG implant and the LNG-IUS.Both progestin-only contraceptives significantly reduced two out of the three biomarkers evaluated. These two biomarkers could, therefore, be used as surrogate markers to follow up medical treatment of endometriosis-associated pain.

OBJECTIVE To design and fabricate a subcutaneous contraceptive implant insertion simulator, and to characterize the performance of nursing students trained with and without the simulator. METHOD A cross-sectional study was conducted on nursing students in Ghana who had no previous training in the insertion of contraceptive implants. They were given standardized training in insertion of implants from 25 April to 26 April, 2016, and then were randomly assigned to an intervention or control group. The control group watched insertions of live implants while the intervention group practiced using the simulator. Local materials were used to fabricate the simulator. The performance of both groups was assessed after the training. RESULTS The participants consisted of 50 nursing students. Those in the intervention group were more likely to: insert the implant accurately (95.2% vs 78.4%, P

Introduction Implants are a new dosage form in development for HIV pre‐exposure prophylaxis (PrEP) with potential for high adherence given that they are provider‐administered and are intended for long‐acting protection. Integrating end‐user preference into early stage product development may further overcome challenges with future product uptake and adherence. Hence, we sought to optimize the design of a PrEP implant in early‐stage development by gathering opinions about implant attributes from potential end‐users in South Africa. Methods We conducted 14 focus group discussions (FGDs) with young women and men aged 18 to 24 in Cape Town and Soshanguve, South Africa, inviting participants into discussion as co‐designers. FGDs were homogenous by gender and previous implant experience. During FGDs, we showed prototype devices and followed a semi‐structured guide with questions on history of contraceptive implant use, preferences for physical characteristics of an implant, implant biodegradability, insertion process, participant‐driven ideas for implant design, and social adoption considerations. FGDs were facilitated in English, isiXhosa, Tswana, isiZulu, or Tsonga, audio‐recorded, transcribed into English, and qualitatively coded and analysed. Results In this qualitative sample of 105 youth (68 women and 37 men), 58 participants were from Soshanguve and 47 from Cape Town, and 23% had previously used contraceptive implants. Participants expressed preferences for several implant design features; specifically, longer duration (≥6 months) was more important to most participants than the size or number of devices implanted. A majority preferred a flexible versus stiff implant to minimize palpability, thereby increasing discreetness and comfort. Nearly all participants favoured a biodegradable implant to avoid removal and thus reduce clinic visits. Concerns about the implant centred on its possible side effects and the “plastic” look of the prototype displayed for demonstration. Conclusions This study offers preliminary insights into an implant for HIV prevention that provides long‐lasting protection may be well received among young South Africans. Additionally, flexibility, discreetness, and biodegradability may increase acceptability of the implant. Such end–user feedback is being incorporated into current implant designs in the hope of creating an effective long‐acting PrEP product that is likely to achieve high uptake and adherence in target populations.

Rapid repeat pregnancy is common among adolescent mothers and is associated with increased risks of adverse perinatal and maternal outcomes. Increasing contraceptive uptake among postpartum adolescents may decrease these outcomes through pregnancy prevention. This randomized controlled trial of 100 postpartum adolescent women assessed the effect of a standardized immediate postpartum contraceptive counseling intervention emphasizing healthy birth spacing and the use of long-acting reversible contraceptives (LARC).After a baseline survey about reproductive health and pregnancy intentions, all subjects received routine postpartum contraceptive counseling. The intervention group also received the standardized counseling intervention. All participants had access to immediate postpartum contraceptive implant initiation or to intrauterine device (IUD) insertion at postpartum follow-up. Contraceptive use and repeat pregnancy were assessed quarterly for 12 months. Differences in repeat pregnancy, as well as contraceptive initiation, continuation, and satisfaction were analyzed.There was no difference in repeat pregnancy or contraceptive initiation, continuation or satisfaction between the study groups. However, regardless of group assignment, all subjects who desired the contraceptive implant used the method, compared to 15% of subjects who desired the IUD (p 0.001). Three pregnancies occurred among subjects who desired the IUD versus none amongst subjects who desired the implant (p = 0.10).This standardized postpartum contraceptive counseling intervention did not affect teens' repeat pregnancies or contraceptive use. However, immediate postpartum availability of the contraceptive implant was associated with increased utilization of this method when compared to the IUD. Future postpartum contraceptive efforts should investigate procedures to improve teens' access to postpartum contraception. CLINICALTRIALS.NCT01814930.

To compare the proportion of women receiving same-day long-acting reversible contraception (LARC) between two different models of contraceptive provision adapted from the Contraceptive CHOICE Project.We used a controlled time-trend study design to compare 502 women receiving structured contraceptive counseling in addition to usual care ("Enhanced Care") to 506 women receiving counseling plus healthcare provider education and cost support for LARC ("Complete CHOICE") at three federally qualified health centers. We provided funds to health centers to ensure an "on-the-shelf" supply and no-cost LARC for uninsured women. We recorded the contraceptive method chosen after contraceptive counseling and the healthcare provider appointment as well as the contraceptive method received that day. Among women choosing LARC, we calculated proportions and performed Poisson regression with robust error variance to estimate relative risks for same-day insertion.Participant demographics reflected the health center populations; 69% were black, 66% had a high school diploma or less, 57% were publicly insured, and 75% reported household income less than 101% federal poverty line. There were 153 (30.5%) women in "Enhanced Care" and 273 (54.0%) in "Complete CHOICE" who chose LARC (p0.01). Among women who chose LARC (n=426), those in "Complete CHOICE" were more likely to receive a same-day insertion, 53.8% vs. 13.7% (RRA contraceptive care model that included healthcare provider education and cost support for LARC in addition to structured contraceptive counseling resulted in higher rates of same-day LARC insertion compared to contraceptive counseling and usual care alone.Contraceptive care provision which includes contraceptive counseling, healthcare provider education, and "on-the-shelf", long-acting reversible contraception facilitate same-day initiation of these methods. Interventions that focus solely on contraceptive counseling do not address other structural barriers to same-day contraceptive provision of all methods including cost and provider practice.

Objective This study assessed whether immediate postpartum insertion of levonorgestrel contraceptive implants is associated with a difference in infant growth from birth to 6 months, onset of lactogenesis, or breastfeeding continuation at 3 and 6 months postpartum compared to delayed insertion at 6 to 8 weeks postpartum. Study design We conducted a randomized trial of women in Uganda who desired contraceptive implants postpartum. We randomly assigned participants to receive either immediate (within 5 days of delivery) or delayed (6 to 8 weeks postpartum) insertion of a two-rod levonorgestrel contraceptive implant system. This is a prespecified secondary analysis evaluating breastfeeding outcomes. The primary outcome of this secondary analysis was change in infant weight; infants were weighed and measured at birth and 6 months. We used a validated questionnaire to assess onset of lactogenesis daily in person while participants were in the hospital, and then daily by phone after they left the hospital, until lactogenesis was documented. We used interviewer-administered questionnaires to assess breastfeeding continuation and concerns at 3 months and 6 months postpartum. Results Among the 96 women randomized to the immediate group and the 87 women to the delayed group, the mean change in infant weight from birth to 6 months was similar between groups: 4632 g in the immediate group and 4407 g in the delayed group (p=.26). Among the 97 women who had not experienced lactogenesis prior to randomization, the median time to onset of lactogenesis did not differ significantly between the immediate and delayed groups (65 h versus 63 h; p=.84). Similar proportions of women in the immediate and delayed groups reported exclusive breastfeeding at 3 months (74% versus 71%; p=.74) and 6 months (48% versus 52%; p=.58). Conclusion We found no association between the timing of postpartum initiation of levonorgestrel contraceptive implants and change in infant growth from birth to 6 months, onset of lactogenesis, or breastfeeding continuation at 3 or 6 months postpartum. Implications This study provides evidence that immediate postpartum initiation of contraception implants does not have a deleterious effect on infant growth or initiation or continuation of breastfeeding.

Objective: To assess correlates of long-acting reversible contraceptive (LARC) use, and explore patterns of LARC use among female sex workers (FSWs) in Kenya. Methods: Baseline cross-sectional data were collected between September 2016 and May 2017 in a cluster-randomized controlled trial in Mombasa. Eligibility criteria included current sex work, age 16-34 years, not pregnant, and not planning pregnancy. Peer educators recruited FSWs from randomly selected sex-work venues. Multiple logistic regression identified correlates of LARC use. Prevalence estimates were weighted to adjust for variation in FSW numbers recruited across venues. Results: Among 879 participants, the prevalence of contraceptive use was 22.6% for implants and 1.6% for intra-uterine devices (IUDs). LARC use was independently associated with previous pregnancy (adjusted odds ratio for one pregnancy, 11.4; 95% confidence interval, 4.25-30.8), positive attitude to and better knowledge of family planning, younger age, and lower education. High rates of adverse effects were reported for all methods. Conclusion: The findings suggest that implant use has increased among FSWs in Kenya. Unintended pregnancy risks remain high and IUD use is negligible. Although LARC rates are encouraging, further intervention is required to improve both uptake (particularly of IUDs) and greater access to family planning services.

Background Despite demonstrable safety and efficacy of subdermal contraceptive implants (SCIs), both insertion and removal of SCIs in the arm have been associated with neurovascular complications. The aim of this study was to investigate type and prognosis of nerve injuries associated with SCIs. Methods We performed a comprehensive search of 4 electronic databases for studies pertaining to patients with nerve injury and concurrent SCI. Studies published between January 1987 and June 2017 were included. Implant location, damaged nerves, clinical presentation, preoperative imaging (x-ray, ultrasound, magnetic resonance imaging), neurologic evaluation (nerve conduction studies, electromyography), and treatment methods were reviewed. To outline management strategies, 2 illustrative cases of major nerve injury caused by SCI removal were presented. Results We analyzed 10 studies including 12 patients. Fourteen nerve injuries in 12 patients were reported during SCI insertion (n = 1) and removal (n = 11). Medial antebrachial cutaneous (n = 5) and median (n = 5) nerves were primarily affected. Neuropathic pain was the main symptom. Primary reasons for nerve injury were pulling or grasping of the nerve (n = 9) after mistaking it for the implant. Neurapraxia (n = 7) was the most common lesion and was treated with implant removal and clinical surveillance (n = 6). Five patients completely recovered; the remaining patients continued to have motor and/or sensory deficit at mean follow-up of 0.7 year (range, 0–2 years). Conclusions Nerve injuries related to SCIs are rare but potentially serious. For nonpalpable SCIs, a multidisciplinary approach, including practitioners with experience treating peripheral nerve injuries, is invaluable.

Although long-acting reversible contraception (LARC) use is increasing in the general female population, only 12% of all women who use contraception and 4.8% of nulliparous women in the United States use either the intrauterine device (IUD) or contraceptive implant. In several studies, however, female physicians prefer LARC for contraception. In 2016, an anonymous electronic survey was administered to all U.S. obstetrics and gynecology residents before the start of the annual in-training examination administered by the Council on Resident Education in Obstetrics and Gynecology. The survey included questions about LARC, including personal use. Fifty percent of female residents or the female partners of male residents used IUDs for contraception, 31.3% used combined oral contraceptives, and 3% used a contraceptive implant. Among nulliparous residents, 37.7% used IUDs. This rate of IUD use was five times the rate reported by the general female population and eight times the nulliparous rate in the United States. Obstetrics and gynecology residents understand the benefits of LARC, but have minimal barriers to access. When barriers and cost are removed and the full range of contraceptive options is offered, the majority of contracepting women and adolescents choose LARC. With the high rates of unintended pregnancy and maternal morbidity and mortality in the United States-especially among poor and minority women-all women, regardless of income, race-ethnicity, and career, should have awareness of and access to these effective contraceptive methods.

Nexplanon is a long-acting 4 cm radio-opaque rod shaped contraceptive device implanted in the subdermal layer of the inner, upper arm. Complications from implantation are uncommon and mostly local and minor, including infection at the implantation site with resulting cellulitis or abscess, hematoma, abnormal scar formation, or local damage to nerves and blood vessels. Intravascular insertion is estimated to be at 1.3 per million Nexplanon implants, and migration and embolization is a rare complication of this device. We present a case report of a 16 year old female who presented to the pediatric emergency department with subjective dyspnea and an embolized contraceptive device within a subsegmental branch of the left lower lobe pulmonary artery. After discussion with consultants, interventional radiology was able to successful retrieve the device without complication.

Nerve injuries usually present as pain, numbness, or weakness, and can have devastating consequences for patients. Procedures that are common in primary care can cause nerve injury. Iatrogenic nerve injuries are largely preventable by understanding nerve anatomical course and surface anatomy, and the risky interventions and regions. Most knowledge of nerve anatomical course is derived from early work on cadaver dissection, but modern imaging techniques more accurately map nerve anatomical course in living bodies. We provide an overview of nerve injuries in primary care, discuss updated nerve anatomical course and surface anatomy based on modern radiological evidence, and make recommendations to guide safer interventions in primary care. In New Zealand’s primary care treatment injury claims dataset there were 69 nerve injuries over 4 years (2% of primary care injuries).1 Venepuncture was the leading cause of nerve injury (27; 39%), followed by intramuscular injection (17; 25%), and steroid injection (15; 22%). Venepuncture injured the cutaneous nerve of the forearm (14), and the median (9) and radial (4) nerves; intramuscular injections injured the sciatic (11), lateral cutaneous (3), and axillary (3) nerves; steroid injections injured the median (12, carpal tunnel) and ulnar (3, medial epicondyle) nerves; intravenous cannulation in the forearm injured the superficial radial nerve (4); and minor surgical procedures injured the spinal accessory (3), common fibular (1), sural (1), and ilioinguinal nerves (1). Most nerve injuries were minor, but 17 (25%) were assessed as having major or serious potential consequences. …

AB is a 17-year-old girl who has migraines with aura and presents for contraceptive management. Based on the US Medical Eligibility Criteria for Contraceptive Use, estrogen-containing contraceptives are contraindicated for AB due to an elevated risk of thrombosis given her diagnosis of migraines with aura. After determining which contraceptive methods are safe, comprehensive counseling should start with a discussion of the most effective contraceptive methods including intrauterine devices (IUDs) and subdermal contraceptive implants. AB elects to have an IUD placed which is inserted the same day given it is reasonably certain she is not pregnant and no sedation is required prior to IUD placement. The only mandatory examination needed prior to IUD placement is a bimanual examination and cervical inspection in accordance with the US Selected Practice Recommendations for Contraceptive Use. Finally, condom use at every sexual encounter is recommended to reduce the risk for sexually transmitted infections.

INTRODUCTION:Long-acting reversible contraception (LARC) is an important component of the contraceptive method mix; education and training in LARC provision is an integral skill for women's health care physicians. Performing IUD and contraceptive implant insertions is an Ob/Gyn residency requirement

A 16-year-old girl had a subdermal contraceptive implant (Implanon-NCT®) inserted 22 months earlier that was no longer palpable. The patient used to “play” with the device to check that it was well positioned in her arm. Chest X-ray and computed tomography revealed that the implant has migrated into a pulmonary artery. Complete vascular retraction around it precluded any endovascular retrieval and the patient refused surgery. Focal pulmonary artery thrombosis usually has no clinical significance but may lead to severe consequences in patients with impaired cardiopulmonary function. Consequently, percutaneous or surgical retrieval of migrated intravascular devices is recommended and is more likely to be successful when migration is recent [1]. Only 25% of patients with implant migration report symptoms, including dyspnea and chest discomfort. Identifying risk factors for migration as in our patient may be therefore important to achieve a closer control in some patients and to increase the success rate of an early percutaneous retrieval in case of migration.

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.