Factors associated with removal difficulties of etonogestrel-containing contraceptive implants (Nexplanon®)

Abstract

Background: Nexplanon®'s new applicator system was designed to limit deep implant placements, known to lead to difficult removals. However, removal difficulties still exist and induce specific and potentially severe complications. Our objective was to identify risk factors associated with difficult removals.

Study design: A retrospective single-center study was performed from January 2015 to December 2016. Participants were divided into two groups depending on whether implant was removed during a standard ("standard removal" group) or difficult consultation ("difficult removal" group) after an initial failed removal attempt.

Results: The difficult and standard removal groups comprised 63 and 660 women, respectively. In a univariate analysis, significant intergroup differences were found for weight gain (3.7 ± 7.3 kg in the difficult removal group vs. 1.3 ± 5.1 in the standard removal group), proportion of placements performed in private practice (66.7% vs. 19.8%, respectively), and duration of Nexplanon® placement (29.4 ± 11.3 months versus 26 ± 13.6, respectively). We also reported more frequent sub-brachial fascia placements when Nexplanon® was implanted by a private practitioner (7.5% cases versus 0.4% in hospital implantations, p < 0.001). In a stepwise binary logistic regression analysis, placement by a private practitioner, weight gain >1kg since placement, and duration of implant placement >25 months were confirmed as independent risk factors for removal difficulties (respective risk ratios 7.63 [95% IC 4.35-13.33], 2.10 [1.18-3.70], and 1.91 [1.06-3.44], p < 0.05).

Conclusions: Awareness of these three simple parameters might help physicians to identify "at risk-patients", and suggest a specific consultation before risking a potentially hazardous removal (with its associated, specific morbidity). Our results also emphasize importance of training in implant insertion.

Comment: Long Acting Reversible Contraceptives, like hormonal implants, are a great option for a number of women. However, we also need to be aware of the need for removal, if there is a desire to have a child. The three risk factors which the authors describe: see above, need to be taken into account before scheduling a removal. Furthermore, since placement by a private practitioner brings the most risk, no implant should be inserted by anyone who is not properly trained to do so. (HMV)