Requested Contraceptive Removal and Fertility Planning

A patient may ask for removal of an implant or intrauterine device, or stop a pill, injectable, patch or ring, because she wants to conceive, because of side effects, or for personal reasons. The request is honoured at any time, without requiring a reason, and without delay, pressure or condition from the clinician. Implants and intrauterine devices can be removed whenever the patient wishes. Removal is done only by a trained provider.

Why this matters. Withholding removal is coercive. Patients who cannot get removal may use unsafe means or lose trust in the service.

History. Reason for removal, plans for pregnancy or another method, duration of use, age, previous pregnancies, menstrual pattern, chronic illness, medicines and sexual health.

Assessment before removal. Confirm the method and expiry date, examine the implant site or device threads, and discuss what follows removal.

Fertility after stopping.

Counselling points. There is no waiting period after removal, and no evidence that prolonged use harms fertility. Menstrual cycles may be irregular for a few cycles. Fertility is also determined by age and other conditions.

Preconception assessment. Age, body mass index, chronic disease (hypertension, diabetes, epilepsy, thyroid disease), HIV status and treatment, syphilis and other sexually transmitted infections, immunisation status, smoking and alcohol, medicines that harm a foetus.

Subfertility screen. Considered after 12 months of unprotected intercourse without conception, or 6 months in a woman over 35.

If the patient does not plan pregnancy. Offer a new method at the time of removal, so protection is continuous.

Implant removal. Done by a trained provider under local anaesthesia. Lidocaine 1% (10 mg/mL) infiltrated, up to 4.5 mg/kg without adrenaline, maximum 300 mg (30 mL). Give the patient instructions: keep the area dry for 4 to 5 days, remove the gauze after 1 or 2 days, leave the plaster for a further 5 days, return for swelling or pain.

Intrauterine device removal. Gentle traction on the threads, in any part of the cycle. If the strings are not visible, refer or locate the device.

Injectables. Stop at the due date. Counsel about delay in fertility.

Pills, patch, ring. Stop at any time. Advise barrier methods if pregnancy is not yet planned.

Folic acid. Folic acid 400 micrograms orally once daily starting at least 1 month before conception and continuing for the first 12 weeks. Use 5 mg daily where there is a previous neural tube defect, epilepsy on valproate or carbamazepine, diabetes or obesity.

Optimise health. Control of hypertension, diabetes, epilepsy and HIV before pregnancy. Review teratogenic medicines (for example valproate, methotrexate, warfarin, angiotensin converting enzyme inhibitors, efavirenz where alternatives exist).

Patients living with HIV. Viral suppression on antiretroviral therapy reduces transmission, and partner testing is advised.

Counselling on timing. Intercourse every 2 to 3 days across the cycle is advised. After stopping DMPA, allow time for the effect to wear off.

Reasons for removal due to side effects. Treat the effect where possible, and offer another method.

Follow up. Review within 3 to 6 months for patients trying to conceive, and sooner for new symptoms. For patients who do not plan pregnancy, review the new method at 3 months.

Method decisions. The method choice is the patient’s. If she changes her mind, offer a replacement without delay.

Referral and escalation. Refer after 12 months of unprotected intercourse without conception (6 months over age 35), earlier with irregular cycles, known tubal disease, endometriosis or male factor concerns. Refer for removal of any implant or device that a trained provider cannot remove in the clinic, and refer patients with chronic disease for preconception care.