Contraceptive Implants Session IV B: One-Rod Implant Removal

Implanon Removal: Required Equipment An examination table Sterile surgical drapes and gloves Antiseptic solution Local anesthetic, needles, and syringe Sterile scalpel, forceps (straight and curved mosquito) Skin closure, sterile gauze and compresses Instructions for facilitator: Use the illustration and the information on the slide to describe the equipment required for the removal procedure. Illustration adapted from: Prescribing Information: Norplant® II Levonorgestrel Implants (Jadelle®), NDA 20-544, Supplement 003/Population Council

Implanon/ImplanonNXT Removal: Step 1 Have the client lie on her back with her arm flexed at the elbow. Locate the implant by palpitation and mark the distal end (end closest to the elbow. Wash the area and apply a disinfectant. Instructions for facilitator: Use the illustration and the information on the slide to describe this step in the removal procedure. The removal of ImplanonNXT should only be performed by a provider who is trained to perform the removal procedure. There have been occasional reports of displacement of the implant, usually involving minor movement from the original position. This may complicate localization of the implant and may require a somewhat larger incision and more time. The precise location of the implant is specified on the user card given to the woman at the time of insertion. In the rare cases where ImplanonNXT has not been inserted correctly, the implant might not be palpable. If the implant is not palpable, it may be appropriate to seek consultation or provide a referral. Advise providers that: If they cannot feel the implant, it should be localized by one of 4 methods before removal is attempted. These methods are: -Computed tomography (CT) scan -2-Dimensional x-ray -Ultrasound -Magnetic resonance imaging (MRI) Until the implant is located, the woman should use another non-hormonal method. Surgery without knowledge of the exact localization of the implant is strictly discouraged. Removal of deeply inserted implants should be conducted with caution in order to prevent damage to deeper neural or vascular structures in the arm.

Implanon/Implanon NXT Removal: Step 2 Anesthetize the arm with 0.5-1 ml of lidocaine (1%) at the site of the incision, which is just below the distal end of the implant. Instructions for facilitator: Use the illustration and the information on the slide to describe this step in the removal procedure. Remind the provider to inject the local anesthetic under the implant to keep it close to the skin surface Picture from Implanon NXT Global Training Package

Implanon/Implanon NXT Removal: Step 3 Push down the proximal tip of the implant; a bulge may appear indicating the distal end of the implant. Starting at the distal tip of the implant, make a longitudinal (along the implant) incision of 2 mm towards the elbow Instructions for facilitator: Use the illustration and the information on the slide to describe this step in the removal procedure. Picture from Implanon NXT Global Training Package

Implanon/Implanon NXT Removal: Step 4 B C Gently push the implant toward the incision until the tip is visible. Grasp the implant with mosquito forceps and remove it (see image A) If the implant is encapsulated, make an incision into the tissue sheath and then remove the implant with the forceps (see images B & C) Instructions for facilitator: Use the illustration and the information on the slide to describe this step in the removal procedure. Discuss that If the tip of the implant is not visible, fibrotic tissue might have formed around the implant. This is called encapsulation. The fibrotic tissue can be split by continuing to cut toward the distal tip until the tip is clearly visible. Picture from Implanon NXT Global Training Package

Implanon/Implanon NXT Removal: Step 5 If the tip of the implant is still not visible, gently insert a forceps into the incision and grasp the implant (see image A). Flip the forceps over with your other hand and gently pull out the distal part of the implant (see image B). If needed, carefully dissect fibrotic tissue around the implant and grasp the implant with a second pair of forceps (see image C). With a second forceps, carefully dissect the tissue around the implant. The implant can then be removed. A B C Instructions for facilitator: Use the illustrations and the information on the slide to describe this step in the removal procedure. Picture from Implanon NXT Global Training Package

Implanon/Implanon NXT Removal: Step 6 Close the incision with a skin closure. Apply a sterile gauze and wrap the arm with a pressure bandage. Before the client is discharged, observe her for a few minutes for signs of bleeding from the insertion site. Review post-removal instructions and other key messages. Clean or dispose of the instruments properly. Instructions for facilitator: Use the illustrations and the information on the slide to describe this step in the removal procedure. Remind provider to have woman remove the pressure bandage after 24 hours and the small bandage after 3 to 5 days. Illustrations adapted from: Prescribing Information: Norplant® II Levonorgestrel Implants (Jadelle®), NDA 20-544, Supplement 003/Population Council

Post-removal Options If the woman decided to keep using this method and is still eligible, insert a new implant through the same incision, or if the client prefers, use the other arm. If the woman decided to discontinue using the implant and does not want to become pregnant, counsel her about other contraceptive options. Use the information on the slide to clarify options for clients who decide to continue or discontinue the method. Remind providers to inform their clients that following removal, the contraceptive effects reverse quickly and a woman can become pregnant at a rate similar to women who have not used the method.