Implant Removal

Routine removal takes out a subdermal implant when it reaches the end of its approved duration, when the patient asks, or for a medical reason. It is a minor procedure that must be offered at any time without conditions. It is usually simple when the rods lie at the correct depth and the provider is trained.

Indications.

• Patient request at any time, for any reason.

• End of the approved duration: 3 years for the single etonogestrel rod and the 3-year levonorgestrel system, 5 years for the 5-year levonorgestrel system.

• Wish for pregnancy, unacceptable side effects, or a new condition that contraindicates the method.

• Replacement with a new implant or another method.

Counselling before removal. Ask the reason, offer treatment for problems and discuss alternatives. Plan the next method for the same day: a new implant through the same site, DMPA, an IUD or pills, so that protection has no gap. If pregnancy is wanted, advise folic acid 400 micrograms orally daily and tell her that fertility returns within weeks.

Provider. Only a provider trained in removal should do it. A provider who is not trained must not attempt removal and refers the patient.

Palpation and marking. Palpate each rod along its length and mark both ends with a pen. If a rod cannot be felt, do not proceed with blind removal; arrange imaging.

Equipment. Sterile gloves, antiseptic, drape, lidocaine 1% with syringe and fine needle, scalpel and blade, two curved mosquito forceps, fine straight forceps, adhesive strip, gauze and pressure bandage.

Preparation. Patient supine with the arm flexed and rotated outward. Clean the skin and confirm consent.

Anaesthesia. Inject 1 to 2 mL of lidocaine 1% under the end of the rod nearest the elbow, where the incision will be made. Do not inject over the rod so that it cannot be felt.

Single-rod removal.

• Make a 2 to 3 mm incision at the end of the rod nearest the elbow.

• Press gently on the end nearest the shoulder so that the tip rises toward the incision, then grasp the tip with forceps.

• If a fibrous sheath covers the tip, open it with the scalpel or by blunt dissection with the forceps, then grasp and pull the rod out gently.

• Check that the whole rod has come out (about 40 mm).

Two-rod removal. Remove each rod through the same incision in the same way. Each rod is about 43 mm long. Check that both are whole.

Closure. Close with an adhesive strip and apply gauze and a pressure bandage.

Replacement. When a new implant is wanted, place it through the same incision or in the opposite arm, with new sterile equipment and fresh local anaesthetic.

Difficult removal.

• Deep rod or thick fibrous capsule: extend the incision slightly (to about 5 mm), use blunt dissection and take the rod with forceps. Do not cut blindly.

• Broken rod: retrieve every piece; if fragments remain, arrange removal under imaging.

• Rod cannot be located: stop, give backup contraception and refer for ultrasound localisation.

• Stop exploring if more than a few minutes have passed or bleeding obscures the field.

Other problems.

• Bleeding: pressure for 5 to 10 minutes.

• Infection: flucloxacillin 500 mg orally four times daily for 5 to 7 days.

• Nerve injury: stop and refer.

• Vasovagal reaction: stop, lay the patient flat with legs raised and monitor. Allergy: adrenaline 0.5 mg intramuscularly into the anterolateral thigh.

Instructions. Keep the site dry for 4 to 5 days. Remove the gauze after 1 or 2 days and leave the adhesive strip for 5 more days. Return for swelling, pain or heat.

Contraception. Make sure the new method protects from the day of removal. Fertility returns within weeks, so a patient who does not want pregnancy needs protection at once.

Documentation. Record that the whole rod or both rods were removed, the new method and the date.

Special groups. A patient asking for removal because of side effects is treated the same way as any other; removal is never delayed or refused. Adolescents and postpartum patients need the same counselling on the next method.

Referral and escalation. Refer failed or incomplete removal, non-palpable rods, signs of nerve injury and suspected deep placement.