A 37-year-old woman of Pacific Island descent presents to a clinic for removal of a subdermal contraceptive implant. She recently immigrated to the United States. An in-house interpreter is used for the visit.

The patient reports that the subdermal implant was placed 10 years ago after the birth of her second child. The implant is believed to be Nexplanon, which is a single-rod device that is FDA approved for up to 3 years of use; however, she was told that the device could be used for 5 years. Because she lacked access to health care, she never had the device removed and had not gotten pregnant despite this extended use of the device. Her menses are sporadic and unpredictable. She requests to have the device removed as she would like another child.

On clinical examination, a rod is identified in her left arm. Upon removal of the implant, the patient asks, “What about the second one?” Confused, the nurse practitioner and patient (with the help of the interpreter) continue to dialogue. The patient states that 2 rods were placed in her arm. With continued palpation of the left arm, a second rod is felt and is removed using the same method as the first rod removal (Figure).


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Discussion

Subdermal contraceptive implants provide a constant delivery of low-dose progestin and are a highly effective form of contraception. The method is used worldwide and offers ease of use. Side effects of irregular or prolonged bleeding are the most common reason for early removal of the implant. No long-term effects on fertility have been reported and the implant has a strong safety profile.1

The first contraceptive implant to be marketed in the US was Norplant (Wyeth), a 6-capsule levonorgestrel system. It was inserted in a fan configuration in the medial upper arm and was approved for 5 years of use.1-2 Norplant was first licensed in 1983 and discontinued in 2002 following concerns about efficacy, side effects, and complications from device insertion and removal.

Implanon (Merck) was approved in 1999 and was updated to a radiopaque system as Nexplanon (formerly Merck, now Organon) in 2010. It is a single-rod etonogestrel system that is approved for 3 years of use. It is less androgenic than its predecessors and has a more stable release rate.1 It is this system most practitioners are most familiar with today. According to FDA guidelines, insertion and/or removal of a Nexplanon must be performed by a trained provider who has attended a training program by the device manufacturer. Difficult removals can be referred to highly trained providers, a list of whom are available on the manufacturer’s website.

Jadelle (Bayer) is a 2-rod levonorgestrel system approved in 1996. Jadelle was initially approved for 3 years of use and later granted an extension for up to 5 years of use. The device was approved by the FDA, but never marketed in the United States.1-2 A second 2-rod levonorgestrel system was made by Shanghai Duhua Pharmaceuticals in China (Sino-implant [II]).

Jadelle consists of 150-mg levonorgestrel in 2 silicone-covered rods (4 cm in length). They are placed in a V shape, with the rods placed at a 30-degree angle and 8 to 10 cm above the elbow in the upper arm. Higher doses of levonorgestrel are released during the first 6 to 12 months of use, with the daily dose tapering to a steady 30 to 35 mg per day over the life of the device. To remove the device, a modified U technique is recommended with an incision made between the implants at a point midway between the proximal and distal tips.1-2

Clinical study findings suggest that Jadelle is well tolerated and providers with extensive experience with the Norplant implant prefer the Jadelle system.3 Other providers report that the Jadelle device is easier and faster to remove than the Norplant device.4,5 A Cochrane review found no difference in effectiveness or continuation rates between Jadelle and other subdermal implants.4 Most women who stopped using the device did so to become pregnant.4,5 Irregular bleeding was the second most common reason for discontinuation.3-5

Encountering Contraceptive Implant Devices Used Outside the US

Although the Jadelle contraceptive implant was never marketed in the US, it has been used worldwide. In 2013, more than 6 million Jadelle implants were shipped to 140 low-income countries, according to the United Nations Population Fund Access.2 African nations especially appear to use the Jadelle device frequently.3,4

It is expected that by 2060, 69 million (or 1 in 6) Americans will be foreign-born.6 Some of these recent immigrants are likely to present with a contraceptive device such as the Jadelle system. While it is not possible to be familiar with every drug/device available outside the United States, this patient encounter points to the importance of openness and listening to the patient’s story as well as becoming more culturally competent.

Ann Weltin, DNP, FNP-BC, CNM, is an associate professor (clinical) at the University of Iowa. She has nearly 30 years of experience as an advanced practice nurse. She continues to practice 1 day a week at a Federally Qualified Health Center in Iowa where she works with many recent immigrants and refugees.

References

  1. French V, Darney P. Implantable contraception. Global Library Women’s Medicine. 2008:1-27. doi:10.3843/GLOWM.10399
  2. Rowlands S, Searle S. Contraceptive implants: current perspectives. Open Access J of Contracept. 2014; 5:73-84. doi:10.2147/OAJC.555968
  3. Brache V, Faundes A, Alvarez F, García AG. Transition from Norplant to Jadelle in a clinic with extensive experience providing contraceptive implants. Contraception. 2006;73(4):364-367. doi:10.1016/j.contraception.2005.10.015
  4. Power J, French R, Cowan F. Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy. Cochrane Database Syst Rev. 2007;2007(3):CD001326. doi:10.1002/14651858.CD001326.pub2
  5. Pam VC, Mutihir JT, Nyango DD, Shambe I, Egbodo CO, Karshima JA. Sociodemographic profiles and use-dynamics of Jadelle (levonorgestrel) implants in Jos, Nigeria. Niger Med J. 2016;57(6):314-319. doi:10.4103/0300-1652.193855
  6. Vespa J, Armstrong D, Medina L. Demographic turning point for the United States: Population projections. Population Projections from 2020-2060. February 2020. https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf Accessed January 13, 2022.