Contraceptive Implants Session I: Characteristics of Implants Adapted by Dr Rodica Comendant, based on Training Resource Package for Family Planning: https://www.fptraining.org/ Photo credits: © 2006 David Alexander/CCP, Courtesy of Photoshare

What Are Implants? Progestin-filled rods (each about the size of a match stick) that are inserted under the skin Jadelle: 2-rod system, effective for 5 years Sino-implant (II): 2-rod system, effective for 4 years (possibly 5) Implanon: 1-rod system, effective for 3 years Norplant: 6-capsule system, effective for 5 years (possibly 7); no longer manufactured but some women are still using it Ask participants: What are contraceptive implants? <allow participants to answer> What are some qualities of implants that are unique to this method? <allow participants to answer> How are implants different from other hormonal methods? <allow participants to answer> Which brands of implants are available in the facility where you work (or in their country, pharmacy, or program)? <allow participants to answer> Illustration credits: WHO; Salim Khalaf/FHI

Key Points for Providers and Clients What it is: – Small tubes placed under the skin of inner, upper arm. – Hormones from the tubes blocks sperm from reaching egg and prevents release of egg. How to use: – Specially trained provider inserts and removes implants. – Nothing to remember to do after insertion. What to expect: – Changes in monthly bleeding including irregular bleeding, spotting, heavier bleeding or no monthly bleeding, are common and safe. Important to remember: – Use another method if waiting for appointment. – Use condoms if you need protection from STIs or HIV/AIDS. Give an overview of the key points about implants (What are they, how do they work, What to expect, important points about implants).

Key Points for Clients Safe to use One of the most effective methods Lasts for 3 to 5 years Can be removed any time if you want to get pregnant Ask participants: “What do you think are the most important messages to give clients about implants?” Allow participants to answer and add to the participants’ responses as needed.

Effectiveness of Implants In this progression of effectiveness, where would you place implants? Implants Less effective More effective Male Sterilization Female Sterilization IUDs Progestin-Only Injectables Combined Oral Contraceptives Male Condoms Standard Days Method Female Condoms Spermicides Less effective More effective Ask participants: Where would you put progestin-only implants on this list? <After participants respond, click the mouse to reveal the answer>. The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are sterilization and IUDs. Use Optional Advanced Slide 2 to review and compare the effectiveness of FP methods during correct and consistent use and common use.

Relative Effectiveness of FP Methods # of unintended pregnancies among 1,000 women in 1st year of typical use No method 850 Withdrawal 220 Female condom 210 Male condom 180 Pill 90 Injectable 60 IUD (CU-T 380A / LNG-IUS) 8 / 2 Female sterilization 5 Vasectomy 1.5 Implant 0.5 Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404, Elsevier Inc. Explain that there is another way to look at effectiveness. In this slide we look at how effective FP methods are as they are commonly used. Ask participants: What if these same women were using an injectable? How many would become pregnant. Conduct role plays. See Session Plan and Facilitator’s Guide for instructions and role play scenarios.

Implants: Mechanism of Action Implants work in two ways Suppresses hormones responsible for ovulation Illustration credit: Salim Khalaf/FHI Thickens cervical mucus to block sperm Implants have no effect on an existing pregnancy.

Implants: Characteristics Very safe and 99.95% effective Easy to use Fertility returns without delay when removed Can be used by breastfeeding women Offer health benefits Have side effects Require minor surgery to insert and remove Cannot be initiated and discontinued without provider’s help Provide no protection from STIs/HIV Ask trainees to brainstorm first a list of positive characteristics (advantages) and then negative characteristics of implants. Write these suggested characteristics on a flip chart. Then show the slide of implant characteristics and compare them to the list generated through brainstorming. Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011.

Implants: Health Benefits Reduced risk of symptomatic pelvic inflammatory disease (PID) Reduced risk of iron-deficiency anemia Reduced risk of ectopic pregnancy 6 per 100,000 in implant users 650 per 100,000 in women using no contraception Source: CCP and WHO, 2011; Task Force for Epidemiological Research on Reproductive Health, 1998.

Possible Side Effects of Implants (part 1) Some users report changes in bleeding patterns: First several months: Lighter bleeding and fewer days of bleeding Irregular bleeding Infrequent bleeding No monthly bleeding After about one year: Lighter bleeding and fewer days of bleeding Irregular bleeding Infrequent bleeding Adapted from WHO’s Decision-making tool for family planning clients and providers. Ask the participants: What side effects of implants, have you heard about? Show slides 12 and 13 on side effects. Explain that many women who use implants experience side effects. How would you feel about these side-effects? *Implanon users are more likely to have no monthly bleeding than irregular bleeding.

Possible Side Effects of Implants (part 2) Headaches Lower abdominal pain Acne (can improve or worsen) Weight change Breast tenderness Dizziness Mood changes Nausea, nervousness

Jadelle: Continuation Rates and Reasons for Discontinuation Cumulative Discontinuation Rate per 100 Women 30.5 25.9 24.3 23.4 In the Jadelle clinical trials conducted in the United States and the Dominican Republic, the first-year continuation rate was 82.7 per 100 women, the three-year cumulative rate was 49.5 per 100 women, and the five-year cumulative rate was 27.4 per 100 women. In the first year, 7.1 per 100 women cited menstrual problems as the principal reason for discontinuing the method while 6.8 women per 100 cited other side effects as the principal reason for discontinuing the method. Women who discontinue early due to menstrual problems generally have more pronounced menstrual changes. By the fifth year, the cumulative discontinuation rate per 100 women for non-menstrual side effects—most commonly headache and weight change—was 30.5; desire to become pregnant was 25.9; menstrual problems was 24.3; personal issues, such as a change in marital status or partner or moving outside the study catchment area, was 23.4; and pregnancy was 0.8.1 Menstrual problems are the most common single reason that women discontinue implants. On this chart, the cumulative discontinuation rate due to other side effects is higher because it combines multiple non-menstrual side effects. It is thought that counseling about side effects, in particular menstrual changes, likely reduced the number of women who discontinued implants. Reference: 1. Sivin I, Alvarez F, Mishell DR, et al. Contraception with two levonorgestrel rod implants: A five-year study in the United States and Dominican Republic. Contraception 1998;58:275-82. 0.8 Cumulative Continuation 82.7 66.2 49.5 36.6 27.4 Rate per 100 Women Source: Sivin et al., 1998. Training Resource Package Contraceptive Implants Module Optional Advanced Slide Set