Implant Follow Up

Implants need no routine monitoring visit after insertion. Follow up is driven by site care in the first week, the patient's concerns, changes in health or medicines, and the planned removal or replacement date. Removal must be available at any time on request, without a requirement to justify the decision, and only a trained provider removes an implant.

Lifespans. Etonogestrel 68 mg single rod: 3 years. Levonorgestrel two 75 mg rods: 5 years for the 5-year system, 3 years for the 3-year system.

Return to fertility. Serum progestin is undetectable within days of removal and ovulation usually returns within the first month, so contraception is needed immediately if pregnancy is not wanted.

Effectiveness while in place. About 0.05 pregnancies per 100 women in the first year.

Review at any contact. Ask about bleeding pattern and satisfaction, side effects, new medical conditions (breast cancer, venous thromboembolism, liver disease, migraine with aura, ischaemic heart disease or stroke), new medicines including enzyme inducers, pregnancy intentions and STI or HIV risk.

New conditions affecting continuation.

• Category 3 for continuation: current venous thromboembolism, ischaemic heart disease or stroke during use, migraine with aura that develops or worsens, severe cirrhosis, hepatic tumour, unexplained bleeding before evaluation.

• Category 4: breast cancer.

• Category 2: starting efavirenz, rifampicin, rifabutin or an enzyme-inducing antiseizure medicine.

Reasons for removal. Completed lifespan, desire for pregnancy, unacceptable bleeding or side effects, a new contraindication, or the patient's wish for any reason.

Counselling before removal. Discuss the reason, whether a remedy for side effects is wanted, and the next method. Do not delay or refuse removal to promote continuation; this is coercive.

Instructions after insertion.

• Keep the site dry for 5 days.

• Remove the gauze bandage after 1 day; leave the adhesive plaster for a further 5 days.

• Expect bruising and soreness.

• Return for pain, heat, pus or redness at the site, a rod coming out, or a rod that cannot be felt.

Follow up card. Records the implant type, insertion date and removal date. Advise the patient to keep the card and to return on the removal date or any time with concerns.

Routine removal.

• Palpate and mark the rod tips.

• Clean the skin, infiltrate lidocaine 1%, 1 to 2 mL under the distal tip.

• Make a 2 mm incision over the distal tip, push the rod towards the incision, grasp with forceps, free the fibrous sheath and withdraw.

• For two-rod systems, remove both through one incision at the apex of the V and confirm two complete rods.

• Close with a sterile adhesive strip and pressure dressing.

Instructions after removal.

• Keep the site dry for 4 to 5 days.

• Remove the gauze after 1 to 2 days; leave the adhesive plaster for a further 5 days.

• Return for swelling or pain.

Continuing protection.

• Replacement implant: insert through the same incision at the removal visit; no backup.

• Switch to DMPA: give the first injection at the removal visit; no backup.

• Switch to a combined or progestin-only pill: start on the day of removal; no backup.

• Switch to a copper or hormonal IUD: insert at the removal visit if reasonably not pregnant; no backup.

• No method wanted: explain that fertility returns at once.

• Desiring pregnancy: advise folic acid 400 micrograms daily before conception and pre-pregnancy review of chronic conditions and medicines.

Overdue implant. Remove, exclude pregnancy, replace if wanted, and use backup 7 days unless within 7 days of the start of bleeding.

Monitoring. No routine blood pressure, weight or blood tests are required.

Difficult removal. Fibrous sheathing, deep placement and broken rods make removal difficult. Stop if the rod cannot be grasped after reasonable attempts, use backup, and refer. Do not extend the incision or dissect blindly.

Non-palpable implant. Use backup, locate with high-frequency ultrasound and, for the radiopaque etonogestrel rod, plain X-ray. Removal under imaging by an experienced provider. Measure serum progestin where available if the rod cannot be found.

Broken or incomplete rod. Remove the remaining fragment; if not possible, refer. Retained fragments may continue to release progestin.

Site infection. Clean and give an oral antibiotic covering skin flora; review in 1 week; remove if an abscess forms or infection persists.

Nerve injury. Numbness, paraesthesia or weakness in the ulnar or medial forearm distribution after insertion or removal requires urgent assessment and referral.

Bleeding causing request for removal. Offer a course of ibuprofen 800 mg three times daily for 5 days or, if oestrogen is eligible, ethinylestradiol 30 micrograms with levonorgestrel 150 micrograms daily for 21 days, but remove if the patient prefers.

Referral and escalation. Refer non-palpable or deep rods, failed removal, fragments, suspected nerve or vascular injury, and suspected migration to the chest.