UK provision for removal of non-palpable contraceptive implants.

©FSRH J Fam Plann Reprod Health Care 2009: 35(1) Introduction Over the last 2 years this Journal has seen a flurry of papers and resulting correspondence related to ‘deep’ Implanon® insertion.1–7 More than 3 million women use etonogestrel contraceptive implants worldwide and 180 000 implants are fitted in the UK each year, with these numbers escalating as I write. From post-marketing data the reported rate of complex removal problems is low, running at about 1 per 1000 insertions. However, for a woman suffering nuisance side effects or wanting to become pregnant, this situation is frustrating and, for some, completely intolerable. What improvements have been achieved to date in contraceptive implant provision? A number of meetings have been held with worldwide contraceptive implant ‘experts’. Discussions have focused on the anatomical site for fitting contraceptive implants, the complications associated with insertion, and techniques for removal of deep and often ‘non-palpable’ implants. Dissemination of these discussions has taken place5,6 and the manufacturing company agreed to alter the insertion site instructions, bringing them more in line with the levonorgestrel multirod implants, Norplant® and Jadelle®. The Summary of Product Characteristics (SPC) for Implanon now reads:8 “To minimise risk of neural or vascular damage, Implanon should be inserted at the inner side of the non-dominant upper arm about 8–10 cm above the medial epicondyle of the humerus”. It is surprising that some senior clinicians have misinterpreted this information and have either thought Implanon should be inserted on the under surface of the arm or over the triceps. There has also been concern that some health care professionals are no longer fitting Implanon as they are confused about these new instructions. Very little has changed. The insertion site can now be moved out of the sulcus between the biceps and triceps (“Tiger Country” for ‘deep implant removers’)9 and many choose to insert it subdermally over the biceps on the anterior side of the non-dominant arm.10 Those who wish to insert Implanon in the sulcus may continue to do so as the SPC advice does not contraindicate this.