1. Contraceptive Implants
Session III: Providing Implants
Photo credits: © 2006 David Alexander/CCP, Courtesy of Photoshare

2. When to Start Implants (A Review)
What if this client, who has no medical conditions that would preclude implants use, wants to initiate implants?
Client situation:
In day 4 of menstrual cycle
Condom user in day 8 of menstrual cycle
2½ weeks postpartum, not breastfeeding
2½ weeks postpartum, breastfeeding
Injectable user, amenorrheic, within reinjection window
IUD user, mid-cycle, had sex since last menses
After taking emergency contraceptive pills (ECPs)
Divide trainees into groups and assign the following questions:
Ask participants to explain what they would do in each case. The correct approaches for each case are outlined below.
In day 4 of menstrual cycle—can have implants inserted immediately, no need to rule out pregnancy or use a backup method (regardless of type of implant being inserted)
Condom user in day 8 of menstrual cycle—ensure client has used condoms consistently and correctly, can have implants inserted immediately, instruct her to continue using condoms for 7 more days
2½ weeks postpartum, not breastfeeding—can have implants inserted immediately, no need to use a backup method
2½ weeks postpartum, currently breastfeeding and wishes to continue—must be at least six weeks postpartum before initiating implant use because of the theoretical concern that progestin from the implant that gets into the breast milk may have an adverse effect on a newborn during the first six weeks after birth.
Injectable user, amenorrheic, within reinjection window—can have implants inserted immediately, no need to rule out pregnancy or use a backup method.
IUD user, mid-cycle, has had sex since her last menses—can have implants inserted immediately, remove IUD during the next menstrual cycle (this is because ovulation may have already occurred and viable sperm may be present in her fallopian tubes so implants even in combination with a back-up method would not be effective).
After taking emergency contraceptive pills (ECPs)—can be inserted within seven days after the start of her next monthly bleeding (within five days for Implanon) or any other time it is reasonably certain she is not pregnant; give her a backup method, or oral contraceptives to start the day after she finishes taking the ECPs, to use until the implants are inserted.

3. Key Counseling Topics for Implant Users
Safety and efficacy
How Implants work
Health benefits
Possible side effects
No protection from STIs/HIV
Inform provider she has an implant in case of serious new health problem
Reasons to return: questions, concerns or experiencing any warning signs
Ask participants: What are the key counseling topics for new Implant users? <allow participants to respond, affirm correct responses and click mouse to reveal the list>
Use slide to present the following:
After a client makes an informed choice to use implants, and you determine that she has no known conditions that would prohibit use, you and the client should discuss in greater detail how to use implants and address any additional questions or misconceptions that the client may have about the characteristics of implants.
Specifically, you should discuss how safe and effective implants are, how efficacy is affected by a woman’s ability to take pills on time, how implants work, health benefits, and possible side effects
You should also discuss the fact that implants do not protect against STIs/HIV.
During counseling, help the client to assess her risk of acquiring or transmitting infection and discuss the benefits and feasibility of condom use to reduce that risk. Explain how to use condoms correctly and consistently and, if needed, help women develop and practice strategies to negotiate condom use with their partners.
Tell the client that if she is diagnosed with any serious new health problem she should inform her health care provider she has a contraceptive implant in place.
Finally, discuss when to return, and tell the client about the warning signs of possible complications. We will discuss the warning signs in a few moments.
Conduct Role Plays: Use Session Plan for instructions.

4. Correcting Rumors and Misunderstandings
Implants stop working once they are removed. Their hormones do not remain in a woman’s body.
They can stop monthly bleeding, but this is not harmful. It is similar to not having monthly bleeding during pregnancy. Blood is not building up inside the woman.
Implants:
Do not make women infertile
Do not move to other parts of the body
Significantly reduce a woman’s risk for ectopic pregnancy
Ask participants: What are some common misconceptions about progestin-only implants? <participants brainstorm; accept responses from several participants>
Let us compare your responses with some of the popular misconceptions that have developed about implants. <click the mouse to reveal the list>
In general, rumors arise when:
An issue or information is important to people, but it has not been clearly explained.
There is nobody available who can clarify or correct the incorrect information.
The original source is perceived to be credible.
Clients have not been given enough options for contraceptive methods.
People are motivated to spread them for political reasons.
A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.
Discuss methods for counteracting rumors and misinformation
When a client mentions with a rumor, always listen politely. Don't laugh.
Define what a rumor or misconception is.
Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor.
Explain the facts. Use strong scientific facts about FP methods to counteract misinformation.
Always tell the truth. Never try to hide side effects or problems that might occur with various methods.
Clarify information with the use of demonstrations and visual aids.
Give examples of people who are satisfied users of the method (only if they are willing to have their names used). This kind of personal testimonial is most convincing.
Reassure the client by examining her and telling her your findings.
Counsel the client about all available FP methods.

5. Counseling about Implants: Additional Key Counseling Topics
Explain the insertion and removal procedure
Provide post-insertion instructions
Explain the length of protection and when to return for removal or replacement
Describe reasons to return for follow-up
Ask participants: What are some other key counseling topics related to implants? <participants brainstorm; accept responses from several participants>
Let us compare your responses with the slide. <click the mouse to reveal the list>
In addition to the topics we have already discussed, it is imperative that during counseling about implants providers also:
Explain the procedure used to insert and remove the implants. Use illustrations if possible. Include the length of time it takes to complete the procedure, who will perform it, and that it may be somewhat uncomfortable but not painful.
Provide post-insertion instructions so that a client knows how to care for the incision and when to return to the clinic if something does not seem right. We will also review these instructions in more detail.
Explain how long the implants protect against pregnancy. Help women remember when they should come back to have the implants removed or replaced. All clients should be provided with the following information:
Type of implant
Date of insertion
Month and year when implants will need to be removed
Where to go in case of questions or problems
A reminder card like the one shown on the slide can be useful for this purpose.
Finally, the provider should advise a client about circumstances that require her to return, which are described in more detail on the next slide.

6. Counseling About Side Effects
Before insertion, describe possible side effects:
Changes in bleeding pattern (most common)
Headaches, breast tenderness, mild abdominal pain (less common)
Explain that side effects:
Are not signs of illness
Often subside within the first year
Encourage the client to come back with questions or concerns
If the client cannot tolerate side effects, management or discontinuation may be necessary
Use the slide to present the following important points:
Counseling—both prior to insertion and for women already using implants—is the best way to help women manage the side effects associated with progestin-only implants.
The most common side effects of implants are irregular bleeding, prolonged bleeding, infrequent bleeding, or no bleeding at all. Headaches, mild abdominal pain, and breast tenderness are examples of less common side effects.
Women who are considering using implants should be counseled that menstrual changes are expected and that they are not signs of disease or health problems. For the majority of women, side effects will become less pronounced or will stop within the first year. Some women may not have any side effects.
After an implant is inserted, the practitioner should tell the client to come back with any questions or concerns. Ongoing counseling and reassurance should be provided if needed.
If the user continues to be concerned or finds the side effects unacceptable, it may be necessary to manage the side effects or remove the implants.

7. Implant Insertion and Removal
Insertion and removal should be quick and easy.
Injection prevents pain.
Provider puts 1 or 2 rods just under the skin of inside upper arm.
Provider bandages opening in skin and wraps the arm—no stitches.
Need to be removed after 3 to 5 years, depending on the type of implant and your weight.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
A client who has chosen an implant needs to know what will happen during insertion. Clients will want to know the following:
Implants usually only take a few minutes to insert, but can sometimes take longer.
Complications related to the insertion are rare.
The provider will carefully clean the area on the arm and will use sterile gloves and equipment.
The client will receive a small injection under the skin so that she will not feel the implant being inserted. The injection may sting a bit.
The client will be awake during the procedure.
The provider will make a small incision on the inside of the upper arm.
The provider will insert the implant (1 or 2 rods, depending on the type.
After the implant has been inserted the provider will put on a small bandage and then gauze will be wrapped around the arm to keep the area clean.
Conduct Role Play: Use Session Guide for instructions

8. What to Remember Keep the insertion area dry for 4 days.
Expect a bit of soreness and bruising.
Come back when it is time to have the implants removed.
Side effects are common but rarely harmful Come back if they bother you.
Come back any time if you have problems or want implants removed.
See a nurse or doctor if:
Yellow skin or eyes
May be pregnant, especially if pain or soreness in belly
Unusually heavy or long bleeding
Infection or continued pain in the insertion site or sees rod coming out
A bright spot in your vision before bad headaches
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Use slide to present the following:
Key messages that clients remember.
Scheduled follow-up visits are not necessary for implant users, but clients should be advised to return to the clinic anytime they have questions or concerns.
Discuss how to remember when to have the implant removed.
Having contact with the client within the first two to six months may improve continuation among women experiencing side effects, because this is when such problems are most likely to occur.
The provider should also ask whether the client’s reproductive goals have changed, as she may want to become pregnant or desire a long-acting or permanent method.
If the client reports or complains about side effects, the provider should assess her symptoms and, if appropriate, reassure her that the side effects are not harmful and discuss ways to manage them.
If the client has developed any conditions that are contraindications for continuing to use implants, or if the client finds side effects unacceptable, the provider should help her choose another method.

9. Helping Continuing Implant Users
No routine visit required, but if she returns, ask:
Whether satisfied with method or has questions.
If she is concerned about bleeding changes.
About new health problems or major life changes (plans for more children, change in STI/HIV risk).
Significant weight changes.
If she wants to continue using implant and has no new medical condition, remind her how much longer her implant will protect her.
Explain that no routine visit required for implants, but if she returns, ask:
Whether satisfied with method or has questions.
If she is concerned about bleeding changes.
About new health problems or major life changes (plans for more children, change in STI/HIV risk).
About significant weight changes (if using Jadelle, significant weight gain may affect the duration of the implants’ effectiveness).
If she wants to continue using implant and has no new medical condition, remind her how much longer her implant will protect her.

10. Management of Implant Side Effects: Bleeding Changes
Counseling and reassurance are key
Problem
Action/Management
Heavy or prolonged bleeding
Reassure the client that this is common and not harmful
Recommend a 5-day course of ibuprofen (up to 800 mg 3 times per day for 5 days)
If no relief, offer COCs for 3 weeks
If bleeding is heavy, iron tablets may prevent anemia
Amenorrhea
Reassure client
For short-term relief offer ibuprofen or indomethacin 2 times daily after meals for 5 days
Ask participants: What is the most important thing that you can do for women who experience side effects? <participants brainstorm; accept responses from several participants> Let us compare your responses with the slide. <click the mouse to reveal the answer>
As we have discussed, the best way to reduce the anxiety some women feel when they experience side effects is to provide detailed information about possible side effects before implant insertion. If side effects occur, the first step is to address the client’s concerns through follow-up counseling.
If a client complains about irregular or breakthrough bleeding, the provider should explain that implants make the uterine lining thinner, sometimes causing it to shed earlier than usual, resulting in this type of bleeding. It is also important to reassure the woman that this bleeding does not mean that anything is wrong and remind her that it will likely diminish with time.
If the irregular bleeding is unacceptable to the client, the provider may recommend up to 800 mg of ibuprofen, or an equivalent amount of another non-steroidal anti-inflammatory drug (NSAID) other than aspirin, three times per day for five days. Women who are experiencing irregular bleeding should not take aspirin, since it may increase bleeding, not decrease it.
If an NSAID does not provide relief, the provider can give a low-dose combined oral contraceptive (COC) containing the progestin levonorgestrel for 21 days. An alternative to COCs is to give 50 µg ethinyl estradiol daily for 21 days. If bleeding is prolonged or heavy—twice as long or twice as much as usual—the provider can suggest that the woman take iron tablets to help prevent anemia. If irregular or heavy bleeding continues to bother the client or starts after several months of normal monthly bleeding or amenorrhea, the provider should rule out a possible underlying condition unrelated to method use, such as uterine fibroids, an STI, genital cancer, or pregnancy.
Amenorrhea is another common side effect of implants. Providers can reassure their clients that it does not indicate a health problem and no medical treatment is necessary. This side effect is similar to not having monthly bleeding during pregnancy.
If side effects persist and are unacceptable to the client, the provider should help her choose another contraceptive method.
Source: CCP and WHO, 2011.

11. Management of Implant Side Effects: Non-Menstrual Problems
Action/Management
Common headache
Reassure and suggest painkillers; evaluate headaches that worsened since implant initiation
If side effects persist and are unacceptable to the client, counsel about non-hormonal methods
Mild abdominal pain
Reassure; suggest pain- killers; follow-up if needed
Breast tenderness
Recommend a supportive bra, compresses, or painkillers
Weight change
Inform about healthy eating habits and exercise
There are several non-menstrual side effects that clients who are using implants may experience.
If a client experiences frequent headaches that are not migraines, reassure her that ordinary headaches do not indicate dangerous conditions and usually diminish over time. Standard doses of painkillers such as aspirin, ibuprofen, paracetamol, or other pain relievers may be used to alleviate symptoms. However, if headaches get worse or occur more often after insertion of implants, they should be evaluated.
Mild abdominal pain may be caused by many conditions, including enlarged ovarian follicles or cysts. Reassure the client that ovarian follicles or cysts usually disappear on their own and standard doses of painkillers or other local remedies will usually alleviate discomfort. To be sure the problem is resolving, see the client again in six weeks. There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. However, if abdominal pain becomes severe, refer at once for immediate diagnosis and care. This is especially true if the severe abdominal pain occurs with other signs or symptoms of ectopic pregnancy such as abnormal vaginal bleeding or no monthly bleeding (especially if this is a change from her usual bleeding pattern), light-headedness, dizziness, or fainting. Ectopic pregnancy is rare but can be life-threatening.
Clients who experience breast tenderness may try wearing a supportive bra and can apply hot or cold compresses. They can also take standard doses of painkillers such as aspirin, ibuprofen, or paracetamol.
In case of weight gain, review the client’s diet and counsel her about healthy eating habits and exercise as a way to better control her weight.
If side effects persist and the client wants to stop using implants, health care providers should counsel about non-hormonal options and help the woman choose another method.
If appropriate, for more advanced providers, discuss Optional Advanced Slide 6: Jadelle: Continuation Rates and Reasons for Discontinuation.
Source: CCP and WHO, 2011.

12. Management of Implant Side Effects: Problems Related to Insertion
Action/Management
Pain after insertion or removal
Check that the bandage or gauze is not too tight; replace bandage; avoid pressing on site
Give painkillers for a few days
Infection
Clean the infected area
Give antibiotics for 7–10 days
Remove implants if no improvement
Abscess
Clean, cut open, and drain the abscess
Treat the wound
Expulsion or partial expulsion
Expulsion or partial expulsion of the implants often follows an infection
Ask the client to return for follow-up care if she notices an implant coming out
Clients may sometimes experience problems related to the insertion of implants.
Ask participants to brainstorm what side effects may occur as a result of insertion and what advice would they give to the client. These problems can usually be addressed easily.
For pain after insertion, check that the bandage on the client’s arm is not too tight. Put a new bandage on the arm and advise the client to avoid pressing on the site for a few days. Standard doses of aspirin, ibuprofen, paracetamol, or other pain reliever may also be helpful.
If the woman experiences redness, heat, pain, or pus at the insertion site, this may indicate an infection. In this case, do not remove the implants. Clean the infected area with soap and water or antiseptic. Give oral antibiotics for 7 to 10 days. Instruct the client to take all the antibiotics. If the infection has not cleared after completing the course of antibiotics, ask the client to return for removal of the implants.
In some cases, the client may develop an abscess—a pocket of pus under the skin caused by an infection. If this happens, clean the area with antiseptic. Cut open and drain the abscess, and treat the wound. Give the woman oral antibiotics for 7 to 10 days. Instruct the client to take all the antibiotics. If she still has signs of infection—such as heat, redness, pain, or drainage of the wound—after completing the antibiotics, ask the client to return for removal of the implants.
Expulsion or partial expulsion of the implants often follows an infection. Ask the client to return for follow-up care if she notices an implant coming out.
Source: CCP and WHO, 2011.

13. Problems That May Require Switching from Implants to Another Method (Part 1)
Action/Management
Unexplained vaginal bleeding
Refer or evaluate by history and pelvic exam
If an STI is diagnosed, treat with implants in place
If no cause can be found, consider removing implants to make diagnosis easier
Migraines
If the client develops migraines with aura after implants are inserted, the implants should be removed
Help client choose a method without hormones
Blood clots, liver or heart disease, stroke, or breast cancer
Remove implants
Treat or refer to a specialist for treatment
As a review, brainstorm side effects and their management. Then discuss problems that may require switching to another method.
Explain that there are some serious health conditions that may require a client to stop using implants. These include:
If a client experiences unexplained vaginal bleeding or heavy or prolonged bleeding that is suggestive of a medical condition not related to the method, she might need to discontinue use of implants.
Refer the client or evaluate by taking her medical history and doing a pelvic examination. Diagnose and treat as appropriate.
If no cause of bleeding can be found, consider stopping implants to make the diagnosis easier. Provide the client with another contraceptive method of her choice until the condition is evaluated and treated. The alternative method should be something other than progestin-only injectables or a copper-bearing or hormonal IUD.
If the bleeding is caused by an STI or PID, the client can continue using implants during treatment.
Although women who have migraine headaches with an aura can initiate implants, implants should be removed if a woman develops migraines with aura after implants are inserted. The provider should help her choose a non-hormonal method.
If a woman develops health conditions such as blood clots in the deep veins of the legs or lungs, heart disease due to blocked or narrowed arteries, severe liver disease, or breast cancer, the implants must be removed.
Although women with ischemic heart disease and women who have had a stroke can initiate use of implants, use of implants should be discontinued if these conditions develop or get worse while using implants.
Remove the implants or refer for removal and give the woman a backup method to use until her condition is evaluated. Refer her for diagnosis and care if she is not already receiving treatment.
Finally, if a woman is pregnant, the implants should be removed. However, there are no known risks to a fetus conceived while a woman has the implants in place.
Source: CCP and WHO, 2011.

14. Problems That May Require Switching from Implants to Another Method (Part 2)
Action/Management
Heart disease due to blocked or narrowed arteries (ischemic heart disease)
A woman who has one of these conditions can safely
start implants. If, however the condition develops while
she is using implants:
Remove the implants or refer for removal
Help her choose a method without hormones
Refer for diagnosis and care if not already under care
Suspected pregnancy
Assess for pregnancy, including ectopic pregnancy
Remove the implants or refer for removal if she will carry the pregnancy to term
There are no known risks to a fetus conceived while a woman has implants in place
As a review, brainstorm side effects and their management. Then discuss problems that may require switching to another method.
Source: CCP and WHO, 2011.

15. Complications from Implants Are Uncommon or Rare
Infection at insertion site
If occurs, most likely within the first 2 months
Difficult removal
Rare if inserted properly and removed by a trained provider
Expulsions
Rare; most occur within the first 4 months
Whereas side effects—especially those related to menstruation—are relatively common with progestin-only implants, complications are uncommon or rare. They may include:
Infection at the insertion site is an uncommon complication. If an infection occurs, it will most likely be within the first two months.
Difficulty with removal may occur if insertion was done improperly or if removal is attempted by an untrained provider. However, if implants are properly inserted and removed by a trained provider, difficulty in removing implants is rare.
Expulsion of an implant is a rare complication. If this occurs, it is most likely to happen in the first four months. If no infection is present, a fresh implant may be inserted through a new incision near the other rods or capsules to replace the one that was expelled.
Source: CCP and WHO, 2011.

16. Counseling about Implants: Explain Removal Procedure to Client
Prior to removal, the provider should tell the client that:
An injection of local painkiller is given. The client stays awake.
A small cut is made near the implant.
A special instrument is used to pull out each implant. The client may feel tugging or slight pain.
The site may be sore for a few days.
The cut is closed with an adhesive bandage; no stitches.
The cut is covered and wrapped with gauze.
Prior to removal, a provider should describe for the client that removing implants usually takes somewhat longer than insertion. Providers should also reassure clients that complications related to implant removal are rare.
The simplified description, from the Global Handbook page shown on the slide, is designed to explain the removal procedure to clients. <participants take turns reading the steps aloud>
The provider uses proper infection prevention procedures.
The woman receives an injection of local anesthetic under the skin of her arm to prevent pain during implant removal. This injection may sting. She stays fully awake throughout the procedure.
The health care provider makes a small incision in the skin on the inside of the upper arm, near the site of insertion.
The provider uses an instrument to pull out each implant. A woman may feel tugging, slight pain, or soreness during the procedure and for a few days after.
The provider closes the incision with an adhesive bandage. Stitches are not needed. An elastic bandage may be placed over the adhesive bandage to apply gentle pressure for two or three days and reduce swelling.
If a woman wants to continue using implants, a new set of implants may be inserted through the same incision, either in the same or in the opposite direction.
Providers must not refuse or delay when a woman asks to have her implants removed, regardless of the reason.
All staff must understand and agree that clients must not be pressured or forced to continue using implants.
Source: CCP and WHO, 2011; Bayer.

17. Infection Prevention: Prior to Implant Insertion or Removal
Getting ready
Have the client wash her arm
Cover the procedure table
Prepare a clean instrument tray
Open the sterile instrument pack
Before insertion/removal
Wash hands thoroughly and put on gloves
Clean the insertion/removal site
Use a sterile drape with a hole over the site
Use a new disposable syringe and needle
Inserting and removing progestin-only implants are minor surgical procedures, and it is important that providers follow careful infection prevention procedures with every client.
Ask participants to brainstorm: “What steps should you take to prevent infection prior to, during, and after the insertion or removal procedure?” <participants brainstorm; accept responses from several participants; click the mouse to reveal the information on the slide>
Source: INFO Reports, 2007.

18. Infection Prevention: After Implant Insertion or Removal
Stop any bleeding with gauze and clean the insertion/removal site
Apply a sterile adhesive bandage
Place sharps in a safety container
Decontaminate instruments
Dispose of contaminated objects
Sterilize instruments and gloves
Decontaminate all surfaces
Wash hands with soap
Source: INFO Reports, 2007.

19. Implants: Summary
Implants are a new option that fulfills an unmet need for many women
Provides long-term protection
Safe and easy to use
Highly effective and readily reversible
Appropriate for most women, including young and nulliparous
Little is required of the client once the implant is in place
Irregular bleeding patterns may be a problem for some women
Thorough counseling is essential
Summarize the important points about implants.
Conduct Role Plays: Follow the step-by-step instructions in the Facilitator’s Guide section on facilitating role plays to prepare for and conduct this activity.
Discussing Case Studies: Ask each group to review the case studies and answer the questions. Case Studies are found in the Facilitator’s Guide.