Over the past few years, there have been changes to recommendations on contraceptive implants with practical implications for clinicians. The most important change in practice is in the recommended site for implant insertion.
It is important to insert contraceptive implants in a consistent position to reduce the incidence of complications during insertion and removal, and to assist practitioners to locate a device when removal is required.
Worldwide, there have been a number of reports of complications when nerves or blood vessels have been injured during insertion. Anatomical studies performed over the past few years have showed that the risk of complications is lowest if implants are inserted superficially and over the triceps muscle.
The guidance is to insert 8-10cm above the medial epicondyle of the non-dominant arm at a distance of 3-5cm posterior to the groove between the biceps and the triceps muscle. An additional mark should be made 5cm above the insertion site to guide placement of the local anaesthetic and the implant along the same track.
It’s very important to insert the implant as superficially as possible to reduce the risk of complications and difficulties with removal. A quick tip for the insertion procedure is to insert only the tip of the needle under the skin before lowering the insertion device to the horizontal position and raising (or ‘tenting’) the skin above the needle, before inserting any further.
What should we do if an implant is due for replacement, and the current one is not in the correct position? It is safer for the patient if the new implant is placed over the triceps, according to the new recommendations, rather than replaced in the original position, which would increase the risk of nerve or vessel complications.
Contraceptive implant removals are usually more challenging to perform than insertions. Some practical tips are:
- Don’t start the procedure if the lower end is not easily palpable. Instead, refer to an experienced practitioner who can perform removal under ultrasound guidance, such as the experts at KEMH.
- Ensure that the incision made is a vertical one. We are aware that some practitioners have been taught the alternative, but removals are much easier if the manufacturer’s advice to do a vertical incision is followed.
- Stabilising the two ends of the implant between finger and thumb throughout the removal generally makes the process easier. This can take some practice. If people would like to practice this on a simulation arm, they can get in touch with Clinical Education at SHQ.
Refresher videos on insertion and removal of contraceptive implants are available online.
Questions have been asked about extended use of long-acting contraception during COVID lockdowns. Based on reasonable evidence that contraceptive efficacy remains high for contraceptive implants, copper IUDs and the higher dose levonorgestrel IUD (Mirena) for a year beyond their recommended duration of use, an Australian consensus statement was published by the SPHERE collaboration last year.
During times when face-to-face health care is limited to urgent issues only, patients who are due for replacement of their implant, copper IUD or higher dose levonorgestrel IUD can be advised that replacement can be postponed for up to a year after the usual recommended time.
The family planning organisations across Australia have collaborated to provide brief evidence-based guidance on topical clinical issues, for example on managing bleeding with progestogen only contraception, or obesity and contraceptive implants. This is available by clicking the ‘For Clinicians’ tab on the SHQ website.
Key messages
- The recommended site of insertion for contraceptive implants has changed
- Removal is more challenging than insertion
- Implant change can be delayed in cases of lockdown.
– References available on request
Author competing interests – nil