3/20/2022
Management of Lost Subdermal Contraceptive Implant
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When an etonogestrel contraceptive implant cannot be palpated, pregnancy must first be excluded, and the patient should use an alternative method of contraception until the presence of the implant can be confirmed. Through review of clinical records and examination of the patient, the type of implant and insertion location should be determined. Cases of failed device insertion where no implant was delivered subdermally have been documented.
Migration more than 2 cm from the insertion site is rare, but inadvertent deep placement is estimated to occur once in every 1000 insertions. Recommendations for optimal placement have changed in the past decade to mitigate risks associated with deep insertion; placement is now recommended in the subcutaneous tissue 8 cm from the medial epicondyle and 2 to 3 cm below the sulcus instead of in the sulcus between the biceps and triceps muscles.
A nonpalpable implant must be located before attempted removal. The etonogestrel implant marketed in the United States since 2010 contains barium, making the device radiopaque and allowing for localization via 2-dimensional x-ray, computed tomography, magnetic resonance imaging, or fluoroscopy. Localization can also be accomplished by a skilled physician via ultrasonography using a high-frequency linear array ultrasound transducer. A transducer of 10 MHz or greater is most effective, although typical office ultrasound transducers (5 to 7.5 MHz range) may be sufficient. Ultrasonography is required for devices implanted before 2010.
If the implant cannot be located in either arm, chest x-ray is recommended to rule out migration of the device into the pulmonary vasculature. Such complications are estimated to occur once in every million insertions and most likely result from unintentional placement into the brachial vein. If imaging fails to locate the device, serum etonogestrel should be measured to confirm device presence. Such tests are not commercially available and require assistance from the manufacturer. If negative, there is no implant in situ.
Once a nonpalpable implant has been located, it should generally be removed by a clinician with expertise in localizing and removing nonpalpable implants. The device manufacturer can help locate referral centers and/or specialists. If the implant is located intramuscularly or close to neurovascular structures, removal is recommended in the operating room by a surgeon (eg, orthopedic hand surgeon) familiar with the anatomy of the upper arm under real-time ultrasound guidance. Serious vascular and neurologic injuries have been reported. If the device is not deeply located in the muscle or close to neurovascular structures, then a skilled clinician can remove the device in the outpatient setting. This removal may be done with real-time ultrasound guidance or fluoroscopy or with prior markings on the skin indicating the location and depth of the device. Skin is cleansed, local anesthesia is injected underneath the implant, and a small incision is made at the device’s midpoint. Using blunt dissection to the level of the implant, an atraumatic modified vasectomy forceps is then used to stabilize the implant without crushing while the fibrous sheath is gently dissected off. Once removed, the implant is measured to ensure complete removal.
As the return to fertility is immediate, patients should be offered additional contraception or preconception counseling to meet their individual needs. If the patient desires insertion of a new implant, the provider should consider use of the contralateral arm or a new insertion site. Limited data suggest that reinsertion through a removal site increases risk of subfascial placement.
Further Reading:
American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice; Long-Acting Reversible Contraceptive Expert Work Group. Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol. 2016 Sep;128(3):e69-77. doi: 10.1097/AOG.0000000000001644. PMID: 27548557.
Cohen R, Teal S. Implantable contraception. In: Jensen J, Creinin M, eds. Speroff & Darney’s Clinical Guide to Contraception. 6th ed. Wolters Kluwer; 2020:133-168.
Matulich MC, Chen MJ, Schimmoeller NR, Hsia JK, Uhm S, Wilson MD, Creinin MD. Referral Center Experience With Nonpalpable Contraceptive Implant Removals. Obstet Gynecol. 2019 Oct;134(4):801-806. doi: 10.1097/AOG.0000000000003457. PMID: 31503148; PMCID: PMC6768758.
Initial Publication March 2022, Reaffirmed January 2024.
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