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Original research article
Removal of etonogestrel contraceptive implants in the operating theater:
report on 28 cases
Eric Vidin, Olivier Garbin ⁎, Brice Rodriguez, Romain Favre, Karima Bettahar-Lebugle
Service de Gynécologie, SIHCUS-CMCO, 67300 Schiltigheim, France
Received 21 December 2006; revised 21 February 2007; accepted 27 March 2007
Abstract
Objectives: We describe removal procedures for etonogestrel contraceptive implants in the operating theater. In addition, we discuss the
management of removal of contraceptive implants that are difficult to palpate or are impalpable.
Design: We conducted a retrospective single-center case series analysis of Implanonkremovals conducted at a university hospital between
January 2002 and April 2005.
Materials and Methods: We analyzed case notes for 28 patients who had their contraceptive implant removed in the operating theater.
Results: Intermenstrual bleeding was the principal reason for removal (52.4%). Ten patients already had one attempted removal of their
implant. Preoperative ultrasound localized the implant in all cases. Half of the removals were done under local anesthetic, with three cases
progressing to general anesthesia (11%). Thirty percent of the implants had migrated from their initial implantation, 37% were in
intramuscular tissue and 11% were in the humeral neurovascular sheath. The only postoperative complications were one small seroma and
transient paresthesia in the territory of the ulnar nerve. The implant was not found in one case.
Conclusions: The removal of an implant that is not palpable or difficult to palpate should take place in the operating theater following
localization by ultrasound. Patients must be fully informed about the procedure, including its complications and the risk for failure.
© 2007 Elsevier Inc. All rights reserved.
Keywords: Contraceptive implant; Etonogestrel; Difficult removal; Ultrasound guidance
1. Introduction
The contraceptive implant Implanonk(Organon,
Puteaux, France) has been available in France since May
2001. The implant is a small cylinder that is 40 mm long
and has a diameter of 2 mm. It contains 68 mg of
etonogestrel, the active metabolite of desogestrel. It is
inserted subdermally in the upper medial aspect of the
nondominant arm. This mode of contraception lasts for
3 years and does not require any further patient compliance.
Many studies have demonstrated its efficacy, and some have
reported a Pearl index of zero [1–9]. In September 2005, the
Organon Laboratory reported sales of 400,000 implants in
France and of 1.5 million implants in Europe. Soon after
Implanonkwas launched in the market, physicians were
confronted with occasional difficulties with removing the
implant. The Organon Laboratory nominated a referral team
in each French town to deal with difficult retrievals. We
form one of those teams. The aim of this report was to
describe difficult removals in order to define the manage-
ment of implants when they are difficult to palpate or are
completely impalpable.
2. Materials and methods
We conducted a retrospective study at the gynecology
department of a university hospital (i.e., SIHCUS-CMCO).
We analyzed case notes for patients who had to have their
Implanonkremoved in the operating theater between
January 2002 and April 2005.
The data collected include each patient's age, the level of
experience of the physician who inserted the Implanonk, the
site of implantation, the time between implantation and
Contraception 76 (2007) 35 –39
⁎Corresponding author.
E-mail address: olivier.garbin@sihcus.fr (O. Garbin).
0010–7824/$ –see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.contraception.2007.03.012
retrieval, the patient's reason for removal, the level of
experience of the physician who attempted the removal, the
difficulties encountered at palpation, the information col-
lected during surgery (e.g., type of anesthesia, location of the
implant, difficulties during the operation and operative time),
postoperative complications and type of contraception used
after retrieval of the implant.
3. Results
Twenty-eight cases of Implanonkretrieval in the
operating theater were identified during the study period.
The mean age of the patients was 31±7.5 years (range, 20–
44 years). Their mean body mass index was 23.1±4.9 kg/m
2
(range, 17–33 kg/m
2
).
The implant was inserted by a French gynecologist in
8 cases, by a general practitioner (GP) in 4 cases, by a non-
French gynecologist in 3 cases, by a GP trainee in 1 case
and by a trainee in obstetrics and gynecology in another
case. This information was missing for 11 cases. Seven
implants were inserted in a hospital setting, and 11 were
inserted in a private practice office. This information was
missing for 10 cases.
The average time between insertion and removal of
Implanonkwas 22.8±12 months (range, 5–40 months).
The reasons given by the patients for having their implant
removed are listed in Table 1. The most frequently cited
reasons for Implanonkremoval because of side effects were
metrorrhagia in 52.4%, headache in 23.8% and weight gain
in 14.3%. In a third of cases, removal was performed because
the Implanonkhad reached the end of its period of efficacy
(8/21 cases).
Ten patients already had at least one attempted retrieval.
Eight of them underwent an unsuccessful removal in a
clinic, one had an attempt in the operating theater and
another patient had two attempts in the operating theater
(Fig. 1A and B).
A radiologist performed preoperative ultrasound with a
7.5-Mhz high-frequency probe. In two cases, identification
was difficult, with doubt about the presence of the implant in
one case. In that case, the blood level of etonogestrel was
detected and the patient underwent a magnetic resonance
imaging (MRI) scan. A second ultrasound examination
allowed us to locate the implant.
We were able to determine from the patient records that
15 implants were not palpable and that 11 were palpable
albeit with difficulty in the preoperative examination.
Seventeen patients (61%) had local anesthesia initially;
however, for three of them, it was necessary to proceed to the
use of general anesthesia. Eleven patients had general
anesthesia initially (39%). The average length of the
procedure was 21.5±19 min (range, 5–70 min) for the
11 cases for which the information was available (mostly for
patients who had general anesthesia).
During the surgical procedure, we found that 19 implants
had not migrated from their initial implantation. Eight
implants did migrate outside the original site (30%),
including 1 that moved to the root of the axillary area. One
set of notes did not contain this information. Fourteen
implants were in a subdermal position, and more than a third
(11/28) were in an intramuscular position, most often under
the muscular aponeurosis. Three implants were located in a
Table 1
Reasons given by the patients for having their etonogestrel implant
removed
Reason n(%)
Metrorrhagia 11 (52)
Beyond expiry time 8 (38)
Headache 5 (24)
Weight gain 3 (14)
Spotting 2 (9.5)
Oligomenorrhea 1 (5)
Irritability 1 (5)
The total exceeds 100% because several reasons could have been cited by
the same patient.
Fig. 1. (A) Unsightly scars after two failed attempts at removing Implanonk.
The scars are distant from the Implanonk, whose position is marked by a
dark line on the skin and which was identified by ultrasound. (B) Immediate
postoperative appearance in the same patient. The implant was removed by a
small transverse incision.
36 E. Vidin et al. / Contraception 76 (2007) 35–39
perivascular position, near or touching the brachial artery
(11%). Of the 27 cases for which the implant was retrieved in
the operating theater, only 5 were documented as being
difficult to retrieve. In one case, in which the Implanonkwas
in a deep intramuscular position, the implant was not found
and left in place.
The postoperative complications were a 2-cc seroma,
which necessitated drainage, and paresthesia in the ulnar
nerve area, which spontaneously resolved within 72 h.
The types of contraception chosen after removal of the
implant were the combined oral contraceptive pill in seven
cases, a progestogen-releasing intrauterine system in two
cases, a copper-bearing intrauterine contraceptive device in
one case, the progestogen-only contraceptive pill in one
case and high-dose progestogen administered intramuscu-
larly in another case. Four patients asked for a new
Implanonkto be inserted.
4. Discussion
With a Pearl index of 0.006 (range, 0.004–0.08),
Implanonkis a safe and reliable method of contraception
[9]. Nevertheless, there can be problems with retrieving the
implant. Removal may be necessary because the implant is
no longer effective after 3 years (2.5 years in the case of
obese women) or because of side effects.
Having irregular menstrual cycles is the most common
reason triggering patients to request for early removal of their
Implanonk[3,10,11]. Affandi [10], in a Europe-based meta-
analysis, reported a rate of 23% for removing the Implanonk
within 2 years of its insertion for irregular cycles.
Intermenstrual bleeding was the principal cause of implant
removal (50% of cases). In France, Sergent et al. [3] reported
abnormal cycles in 83% of 182 patients with an Implanonk.
In this study, intermenstrual bleeding was the main cause of
premature removal of the implant (41% of 29 premature
removals). Irregular cycles seem to be less frequent in Chile
and Southwest Asia [6,10]. Our removal rate due to
intermenstrual bleeding is approximately 50%, which is in
keeping with rates reported in most of the occidental
literature. Other patients required removal of the implant
because of other well-known side effects: headache, weight
gain and irritability. Weight gain and irritability are due to
the androgenic activity of the etonogestrel and, along
with acne, are the most often reported side effects after
irregular cycles [7,12,13].
If a patient wishes so or after 3 years of use, Implanonk
must be removed from the arm because it is not biodegrad-
able. It is correct insertion in a good subdermal position that
will determine the implant's ease of removal. Usually,
removal is performed in a clinic by palpating the implant and
making a 2-mm incision at its caudal end and then pushing
the implant toward the incision. One end will come out and is
grasped with forceps/clips —this is known as the pop-out
technique [14]. It is recommended to inject the local
anesthetic under the implant to avoid its disappearance
under the edema after the infiltration.
Times for removing an Implanonkare short according
to the literature —between 2.1 and 5 min [6,7]. A meta-
analysis compared the length of time of removing
Implanonk(633 patients) with that of removing Norplantk
(137 patients), which is a similar but older levonorgestrel-
based device and that which includes six elements to insert.
The mean time for the removal of Implanonkwas 2.6 min,
versus that of 10.2 min for the removal of Norplantk[15].
Data regarding difficult retrievals of Implanonkare rare.
For Sergent et al. [3], 10 of 29 removals under local
anesthesia were deemed to be difficult by the patients. Two
were ultimately performed under general anesthesia. Affandi
et al. [6] reported on one difficult case from among 200,
whereas Croxatto et al. [7] did on 19 of 205 cases (3%).
One case of difficult localization of Implanonk, neces-
sitating ultrasound, computed tomographic scan and MRI,
triggered a national pharmacovigilance survey in France [16].
In 16 months, 11 cases of difficulty with or failure of
Implanonkremoval were reported, giving an incidence of
1/100,000 implants (range, 0.05–0.181). Only 9 of the
implants were finally removed, 2 of them under general
anesthesia. To our knowledge, our series is the largest
published to date concerning removal of Implanonkin the
operating theater. However, it has the obvious limitations
of retrospective descriptive studies.
An impalpable implant must trigger three questions: Has
it really been inserted? Is it in a subdermal or a subcutaneous
or intramuscular position? Has it migrated? The noninserted
implant is responsible for 77% of pregnancies occurring with
Implanonk[16]. In our experience, two patients were
referred for an impalpable implant and were in the first
trimester of their pregnancy. In these two cases, medical
Fig. 2. The implant is best visualized by ultrasound on a transverse plane as
an echogenic spot (white arrow) with a hypoechogenic shadow. The implant
is in a deep intramuscular position. Note the close position of the brachial
pedicle (black arrow).
37E. Vidin et al. / Contraception 76 (2007) 35–39
imaging did not help with visualization of the implant. If in
doubt, the etonogestrel blood level can be determined to
confirm the presence of an implant. When present but not
palpable, the device can be difficult to locate with medical
imaging as it is radiotransparent [9]. This type of problem
was already encountered with Norplantk[9,17]. Ultrasound
using a 7.5-Mhz linear probe allows for identification of the
Implanonk, thanks to the presence of posterior acoustic
shadowing [18] (Fig. 2). It has been suggested that the
procedure be conducted in the ultrasound room, having
marked the site on the skin, to facilitate the retrieval of
the implant. This would avoid the difficulties caused
by changing the position of a patient when she moves
rooms [19]. For some authors, MRI is the best diagnostic
tool for locating an implant not seen with ultrasound [20,21].
It should be noted that the implant is only visible with low-
signal MRI.
Impalpable implants may trigger medicolegal actions.
Difficult retrievals of Norplantkwere responsible for a drop
in its use in the United States, following patient complaints
[22,23]. In 2003, in France, two gynecologists and a GP had
to utilize their professional insurance because they were
being sued for badly positioning implants [24]. In 2004,
three gynecologists and two GPs had similar experiences
[25]. No complaint was made by any patient in our series. It
is paramount to inform every patient when retrieval takes
Fig. 3. Removal of an intramuscularly positioned implant near the brachial pedicle. (A) The implant was identified by ultrasound, and the skin was marked. After
transverse skin incision across the implant, the aponeurosis was exposed. (B) Muscular exposure after aponeurosis incision. (C) Identification of the brachial
pedicle. (D) The implant was more lateral, in an intramuscular position. (E and F) Removal of the implant.
38 E. Vidin et al. / Contraception 76 (2007) 35–39
place in a theater about potential difficulties and the risks for
failure and scarring.
Once identified, an incision of 12–15 mm transverse to
the implant is made (Fig. 3). This is performed near the most
superficial end, which needs to be identified by the
radiologist. The incision may need to be longer when the
implant is deeper or near the humeral pedicle. The material
required is not specific, but small retractors, such as Farabeuf
retractors, may prove to be very useful. It is necessary to cut
the subcutaneous tissue, and the incision of the muscular
aponeurosis may often be necessary. The implant is often
located just underneath it. In cases of deeper location,
dissection needs to be progressive and gentle through the
muscular fibers. The use of a right-angle retractor may be
helpful, as is palpation with the pulp of the little finger in the
incision. Insertion within the muscle is unusual. The
dissection needs to be conducted carefully because of
the presence of arteries and nerves, which appear white,
like the implant.
It is worth noting that in the United Kingdom, the
doctors allowed to insert and remove the implant must be
specifically certified —and their certificate needs to be
renewed every 5 years [26].
5. Conclusions
Removal of an impalpable or barely palpable implant
must be performed in the operating theater after localizing
the implant using ultrasound. Patients must be fully informed
about the procedure, including its complications and the risk
for failure.
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