The single-rod etonogestrel radiopaque contraceptive implant is a long-acting reversible
contraceptive that provides highly effective contraception for multiple continuous
years [
[1]
]. It is FDA approved up to three years with an evidence-based duration up to 5 years
[
[2]
]. The product has gained popularity, and between 2015 to 2017 approximately 5.6% of
the total United States women's contraceptive use was met with contraceptive implants
[
[3]
]. The current implant and inserter are modified from the originally marketed version
with single-handed applicator and addition of barium sulfate to the implant allowing
easier visualization by many imaging modalities [
4
,
5
,
Merck & Co. I. Nexplanon (etonogestrel implant) Label- Prescribing information. [updated 11/2020]. Available from: https://www.merck.com/product/usa/pi_circulars/n/nexplanon/nexplanon_pi.pdf.
6
,
7
]. Implant migration up to 2cm is expected, however clinically significant adverse
effects of the radiopaque contraceptive implant, as a result of its migration, are
exceedingly rare with the incidence of distant migration to the lung parenchyma or
pulmonary vasculature of approximately 1 in 100,000 users [
[8]
,
[9]
]. Although simple to insert and remove, approximately 14/1000 device removals are
reported as difficult and 1/1,000 women are found to have a nonpalpable device at
the time of removal [
[10]
]. These circumstances may arise secondary to device migration, improper insertion,
non-insertion, significant fibrosis, or weight gain. If a nonpalpable implant is encountered,
it is imperative to localize the device prior to attempting removal, and in some instances,
a referral to a specialized center may be required [
[6]
,
11
,
12
,
13
]. Formal networks of expert removal centers have been established in some countries
including the United Kingdom and South Africa [
[10]
,
[14]
]. In the United States, the implant manufacturing company has an unadvertised list
of specialty removal centers [
[14]
]. According to the implant manufacturing company, providers or institutions skilled
in difficult removals can apply to the manufacturing company to become a recognized
referral center for difficult or nonpalpable radiopaque contraceptive implants. The
applicant will undergo an interview, and the implant manufacturers’ Center of Experience
Committee will decide whether to appoint the applicant to become an official specialized
referral center. A comprehensive description of experience of referral centers have
never been presented, however they typically consist of family planning trained clinicians,
with expertise in advanced techniques to localize and remove radiopaque contraceptive
implants including ultrasound using high frequency linear array probes (10 MHz or
greater) and have access to additional resources such as interventional radiology
or surgery if needed [
[14]
]. A provider is encouraged to call the phone number listed in the radiopaque contraceptive
implant prescribing information when they need assistance with a difficult or nonpalpable
implant removal [
[5]
,
Merck & Co. I. Nexplanon (etonogestrel implant) Label- Prescribing information. [updated 11/2020]. Available from: https://www.merck.com/product/usa/pi_circulars/n/nexplanon/nexplanon_pi.pdf.
[10]
]. The implant manufacturing company will then provide the clinician with a nearby
specialized referral center to assist with the case. These experts typically have
more than a 92% success rate at removing difficult or nonpalpable radiopaque contraceptive
implants in the office [
[10]
,
[14]
].Keywords
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Article info
Publication history
Published online: October 11, 2021
Accepted:
October 6,
2021
Received in revised form:
September 30,
2021
Received:
June 12,
2021
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
