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

2. 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

3. 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).

4. 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.

5. 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.

6. 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) , 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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:
0.8
Cumulative Continuation Rate per 100 Women
Source: Sivin et al., 1998.
Training Resource Package Contraceptive Implants Module
Optional Advanced Slide Set