Implants

Implants

Key Points for Providers and Clients

• Implants are small flexible rods or capsules that are placed just under the skin of the upper arm.
• Provide long-term pregnancy protection. Very effective for 3 to 7 years, depending on the type of implant, immediately reversible
• Require specifically trained provider to insert and remove. A woman cannot start or stop implants on her own.
• Little required of the client once implants are in place.
• Bleeding changes are common but not harmful. Typically, prolonged irregular bleeding over the first year, and then lighter, more regular bleeding or infrequent bleeding.

What Are Implants?

• Small plastic rods or capsules, each about the size of a matchstick, that release a progestin like the natural hormone progesterone in a woman’s body.

• A specifically trained provider performs a minor surgical procedure to place the implants under the skin on the inside of a woman’s upper arm.

• Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen.

• Many types of implants:
– Jadelle: 2 rods, effective for 5 years
– Implanon: I rod, effective for 3 years (studies are underway to see if it lasts 4 years)
– Norplant: 6 capsules, labeled for 5 years of use (large studies have found it is effective for 7 years)
– Sinoplant: 2 rods, effective for 5 years

• Work primarily by:
– Thickening cervical mucus (this blocks sperm from meeting an egg)
– Disrupting the menstrual cycle, including preventing the release of eggs from the ovaries (ovulation)

Implants

How Effective?

One of the most effective and long-lasting methods:

• Less than 1 pregnancy per 100 women using implants over the first year (5 per 10,000 women). This means that 9,995 of every 10,000 women using implants will not become pregnant.

• A small risk of pregnancy remains beyond the first year of use and continues as long as the woman is using implants.
– Over 5 years of Jadelle use: About 1 pregnancy per 100 women
– Over 3 years of Implanon use: Less than 1 pregnancy per 100 Less women (1 per 1,000 women) effective
– Over 7 years of Norplant use: About 2 pregnancies per 100 women

• Jadelle and Norplant implants start to lose effectiveness sooner for heavier women:
– For women weighing 80 kg or more, Jadelle and Norplant become less effective after 4 years of use.
– For women weighing 70-79 kg, Norplant becomes less effective after 5 years of use.
– These users may want to replace their implants sooner.

Return of fertility after implants are removed: No delay
Protection against sexually transmitted infections (STIs): None

Why Some Women Say They Like Implants
• Do not require the user to do anything once they are inserted
• Prevent pregnancy very effectively
• Are long-lasting
• Do not interfere with sex

Side Effects, Health Benefits, Health Risks, and Complications

Side Effects

Some users report the following:
• Changes in bleeding patterns including:
First several months:
– Lighter bleeding and fewer days of bleeding
– Irregular bleeding that lasts more than 8 days
– Infrequent bleeding
– No monthly bleeding

After about one year:
– Lighter bleeding and fewer days of bleeding
– Irregular bleeding
– Infrequent bleeding

Implanon users are more likely to have infrequent or no monthly bleeding than irregular bleeding lasting more than 8 days.
• Headaches
• Abdominal pain
• Acne (can improve or worsen)
• Weight change
• Breast tenderness
• Dizziness
• Mood changes
• Nausea

Other possible physical changes:
• Enlarged ovarian follicles

Known Health Benefits
Help protect against:
• Risks of pregnancy
• Symptomatic pelvic inflammatory disease

May help protect against:
• Iron-deficiency anemia

Known Health Risks
None

Complications

Uncommon:
• Infection at insertion site (most infections occur within the first 2 months after insertion)
• Difficult removal (rare if properly inserted and the provider is skilled at removal)
Rare:
• Expulsion of implant (expulsions most often occurs within the first 4 months after insertion)

Correcting Misunderstandings
Implants:
• Stop working once they are removed. Their hormones do not remain in a woman’s body.
• Can stop monthly bleeding, but this is not harmful. It is similar to not having monthly bleeding during pregnancy. Blood is not building up inside the woman.
• Do not make women infertile.
• Do not move to other parts of the body.
• Substantially reduce the risk of ectopic pregnancy.

Who Can and Cannot Use Implants

Safe and Suitable for Nearly All Women

Nearly all women can use implants safely and effectively, including women who:
• Have or have not had children
• Are not married
• Are of any age, including adolescents and women over 40 years old
• Have just had an abortion, miscarriage, or ectopic pregnancy
• Smoke cigarettes, regardless of woman’s age or number of cigarettes smoked
• Are breastfeeding (starting as soon as 6 weeks after childbirth)
• Have anemia now or in the past
• Have varicose veins
• Are infected with HIV, whether or not on antiretroviral therapy

Women can begin using implants:
• Without a pelvic examination
• Without any blood tests or other routine laboratory tests
• Without cervical cancer screening
• Without a breast examination
• Even when a woman is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant

Medical Eligibility Criteria for Implants

Ask the client the questions below about known medical conditions. Examinations and tests are not necessary. If she answers “no” to all of the questions, then she can have implants inserted if she wants. If she answers “yes” to a question, follow the instructions. In some cases she can still start using implants.

1. Are you breastfeeding a baby less than 6 weeks old?

□ NO □ YES She can start using implants as soon as 6 weeks after childbirth.

2. Do you have severe cirrhosis of the liver, a liver infection, or liver tumor? (Are her eyes or skin unusually yellow? [signs of jaundice])

□ NO □ YES If she reports serious active liver disease (jaundice, active hepatitis, severe cirrhosis, liver tumor), do not provide implants. Help her choose a method without hormones.

3. Do you have a serious problem now with a blood clot in your legs or lungs?

□ NO □ YES If she reports a current blood clot (not superficial clots), do not provide implants. Help her choose a method without hormones.

4. Do you have vaginal bleeding that is unusual for you?

□ NO □ YES If she has unexplained vaginal bleeding that suggests pregnancy or an underlying medical condition, implants could make diagnosis and monitoring of any treatment more difficult. Help her choose a method to use while being evaluated and treated (not progestin-only injectables, or a copper-bearing or hormonal IUD). After treatment, re-evaluate for use of implants.

5. Are you taking medication for seizures? Are you taking rifampicin for tuberculosis or other illness?

□ NO □ YES If she is taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, or rifampicin, do not provide implants. They can make implants less effective. Help her choose another method but not combined oral contraceptives or progestin-only pills.

6. Do you have or have you ever had breast cancer?

□ NO □ YES Do not provide implants. Help her choose a method without hormones.

Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable, when relevant to the client.

Using Clinical Judgment in Special Cases

Usually, a woman with any of the conditions listed below should not use implants. In special circumstances, however, when other, more appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s condition and situation may decide that she can use implants. The provider needs to consider the severity of her condition and, for most conditions, whether she will have access to follow-up.

• Breastfeeding and less than 6 weeks since giving birth
• Current blood clot in deep veins of legs or lungs
• Unexplained vaginal bleeding before evaluation for possible serious underlying condition
• Had breast cancer more than 5 years ago, and it has not returned
• Severe liver disease, infection, or tumor
• Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, or rifampicin. A backup method should also be used because these drugs reduce the effectiveness of implants.

Implants for Women With HIV

• Women who are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy can safely use implants.
• Urge these women to use condoms along with implants. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs. Condoms also provide extra contraceptive protection for women on ARV therapy. It is not certain whether ARV medications reduce the effectiveness of implants.

Providing Implants

When to Start

IMPORTANT: A woman can start using implants any time she wants if it is reasonably certain she is not pregnant.

 
Woman’s situation When to start
Having menstrual cycles or switching from a nonhormonal method Any time of the month

• If she is starting within 7 days after the start of her monthly bleeding (5 days for Implanon), no need for a backup method.

• If it is more than 7 days after the start of her monthly bleeding (more than 5 days for Implanon), she can have implants inserted any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after insertion.

• If she is switching from an IUD, she can have implants inserted immediately.

Switching from a hormonal method • Immediately, if she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. No need to wait for her next monthly bleeding. No need for a backup method.

• If she is switching from injectables, she can have implants inserted when the repeat injection would have been given. No need for a backup method.

Fully or nearly fully breastfeeding
Less than 6 months after giving birth
• If she gave birth less than 6 weeks ago, delay insertion until at least 6 weeks after giving birth.

• If her monthly bleeding has not returned, she can have implants inserted any time between 6 weeks and 6 months. No need for a backup method.

• If her monthly bleeding has returned, she can have implants inserted as advised for women having menstrual cycles.

Fully or nearly fully breastfeeding
More than 6 months after giving birth
• If her monthly bleeding has not returned, she can have implants inserted any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after insertion.

• If her monthly bleeding has returned, she can have implants inserted as advised for women having menstrual cycles.

Partially breastfeeding
Less than 6 weeks after giving birth
• Delay inserting implants until at least 6 weeks after giving birth.
Partially breastfeeding
More than 6 weeks after giving birth
• If her monthly bleeding has not returned, she can have implants inserted any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after insertion.

• If her monthly bleeding has returned, she can have implants inserted as advised for women having menstrual cycles.

Not breastfeeding
Less than 4 weeks after giving birth
• She can have implants inserted at any time. No need for a backup method.
 Not breastfeeding
More than 4 weeks after giving birth
• If her monthly bleeding has not returned,she can have implants inserted any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after insertion.

• If her monthly bleeding has returned, she can have implants inserted as advised for women having menstrual cycles.

No monthly bleeding (not related to childbirth or breastfeeding) • She can have implants inserted any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after insertion.
After miscarriage or abortion • Immediately. If implants are inserted within 7 days after first- or second-trimester miscarriage or abortion, no need for a backup method.

• If it is more than 7 days after first- or second-trimester miscarriage or abortion, she can have implants inserted any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after insertion.

After taking emergency contraceptive pills (ECPs) • Implants can be inserted within 7 days after the start of her next monthly bleeding (within 5 days for Implanon) or any other time it is reasonably certain she is not pregnant. Give her a backup method, or oral contraceptives to start the day after she finishes taking the ECPs, to use until the implants are inserted.

Giving Advice on Side Effects

IMPORTANT: Thorough counseling about bleeding changes and other side effects must come before inserting implants. Counseling about bleeding changes may be the most important help a woman needs to keep using the method.

Describe the most common side effects
• Changes in her bleeding pattern:
– Irregular bleeding that lasts more than 8 days at a time over the first year.
– Regular, infrequent, or no bleeding at all later.
• Headaches, abdominal pain, breast tenderness, and possibly other side effects.

Explain about these side effects
• Side effects are not signs of illness.
• Most side effects usually become less or stop within the first year.
• Common, but some women do not have them.
• Client can come back for help if side effects bother her.

Inserting Implants

Explaining the Insertion Procedure for Jadelle and Norplant

A woman who has chosen implants needs to know what will happen during insertion. The following description can help explain the procedure to her. Learning to insert and remove implants requires training and practice under direct supervision. Therefore, this description is a summary and not detailed instructions.

Inserting implants usually takes only a few minutes but can sometimes take longer, depending on the skill of the provider. Related complications are rare and also depend on the skill of the provider. (Implanon is inserted with a specially made applicator similar to a syringe. It does not require an incision.)

1. The provider uses proper infection-prevention procedures.
2. The woman receives an injection of local anesthetic under the skin of her arm to prevent pain while the implants are being inserted. This injection may sting. She stays fully awake throughout the procedure.
3. The provider makes a small incision in the skin on the inside of the upper arm.
4. The provider inserts the implants just under the skin. The woman may feel some pressure or tugging.
5. After all implants are inserted, the provider closes the incision with an adhesive bandage. Stitches are not needed. The incision is covered with a dry cloth and the arm is wrapped with gauze.

Removing Implants

IMPORTANT: Providers must not refuse or delay when a woman asks to have her implants removed, whatever her reason, whether it is personal or medical. All staff must understand and agree that she must not be pressured or forced to continue using implants.

Explaining the Removal Procedure

A woman needs to know what will happen during removal. The following description can help explain the procedure to her. The same removal procedure is used for all types of implants.

1. The provider uses proper infection-prevention procedures.
2. The woman receives an injection of local anesthetic under the skin of her arm to prevent pain during implant removal. This injection may sting. She stays fully awake throughout the procedure.
3. The health care provider makes a small incision in the skin on the inside of the upper arm, near the site of insertion.
4. The provider uses an instrument to pull out each implant. A woman may feel tugging, slight pain, or soreness during the procedure and for a few days after.
5. The provider closes the incision with an adhesive bandage. Stitches are not needed. An elastic bandage may be placed over the adhesive bandage to apply gentle pressure for 2 or 3 days and keep down swelling.

If a woman wants new implants, they are placed above or below the site of the previous implants or in the other arm.

Supporting the User
Giving Specific Instructions

Keep arm dry
• She should keep the insertion area dry for 4 days. She can take off the elastic bandage or gauze after 2 days and the adhesive bandage after 5 days.

Expect soreness,bruising
• After the anesthetic wears off, her arm may be sore for a few days. She also may have swelling and bruising at the insertion site. This is common and will go away without treatment.

Length of pregnancy protection
• Discuss how to remember the date to return.
• Give each woman the following information in writing on a reminder card, like the one shown below, if possible, and explain:
– The type of implant she has
– Date of insertion
– Month and year when implants will need to be removed or replaced
– Where to go if she has problems or questions with her implants

Have implants removed before they start to lose effectiveness
• Return or see another provider before the implants start losing effectiveness (for removal or, if she wishes, replacement).

“Come Back Any Time”: Reasons to Return

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; she has a major change in health status; or she thinks she might be pregnant. Also if:

• She has pain, heat, pus, or redness at the insertion site that becomes worse or does not go away, or she sees a rod coming out.
• She has gained a lot of weight. This may decrease the length of time her implants remain highly effective.

General health advice: Anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the nurse or doctor what method she is using.

Helping Continuing Users

IMPORTANT: No routine return visit is required until it is time to remove the implants. The client should be clearly invited to return any time she wishes, however.

1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.

2. Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs.

3. Ask a long-term client if she has had any new health problems since her last visit. Address problems as appropriate. For new health problems that may require switching methods.

4. Ask a long-term client about major life changes that may affect her needs—particularly plans for having children and STI/HIV risk. Follow up as needed.

5. If possible, weigh the client who is using Jadelle or Norplant implants. If her weight has changed enough to affect the duration of her implants’ effectiveness, update her reminder card, if she has one, or give her a new reminder card with the proper date.

6. If she wants to keep using implants and no new medical condition prevents it, remind her how much longer her implants will protect her from pregnancy.

Managing Any Problems

Problems Reported as Side Effects or Complications

May or may not be due to the method.

• Problems with side effects and complications affect women’s satisfaction and use of implants. They deserve the provider’s attention. If the client reports any side effects or complications, listen to her concerns, give her advice, and, if appropriate, treat.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Irregular bleeding (bleeding at unexpected times that bothers the client)
• Reassure her that many women using implants experience irregular bleeding. It is not harmful and usually becomes less or stops after the first year of use.

• For modest short-term relief, she can take 800 mg ibuprofen or 500 mg mefenamic acid 3 times daily after meals for 5 days, beginning when irregular bleeding starts.

• If these drugs do not help her, she can try one of the following, beginning when irregular bleeding starts:
– Combined oral contraceptives with the progestin levonorgestrel. Ask her to take one pill daily for 21 days.
– 50 µg ethinyl estradiol daily for 21 days.

• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use.

No monthly bleeding
• Reassure her that some women stop having monthly bleeding when using implants, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)

Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)
• Reassure her that some women using implants experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.

• For modest short-term relief, she can try of the treatments for irregular bleeding, above, beginning when heavy bleeding starts. Combined oral contraceptives with 50 µg of ethinyl estradiol may work better than lower-dose pills.

• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).

• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use.

Ordinary headaches (nonmigrainous)
• Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.
• Any headaches that get worse or occur more often during use of implants should be evaluated.

Mild abdominal pain
• Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.
• Consider locally available remedies.

Acne
• If client wants to stop using implants because of acne, she can consider switching to COCs. Many women’s acne improves with COC use.
• Consider locally available remedies.

Weight change
• Review diet and counsel as needed.

Breast tenderness
• Recommend that she wear a supportive bra (including during strenuous activity and sleep).
• Try hot or cold compresses.
• Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.
• Consider locally available remedies.

Mood changes or changes in sex drive
• Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.
• Clients who have serious mood changes such as major depression should be referred for care.
• Consider locally available remedies.

Nausea or dizziness
• Consider locally available remedies.

Pain after insertion or removal
• For pain after insertion, check that the bandage or gauze on her arm is not too tight.
• Put a new bandage on the arm and advise her to avoid pressing on the site for a few days.
• Give her aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.

Infection at the insertion site(redness, heat, pain, pus)
• Do not remove the implants.
• Clean the infected area with soap and water or antiseptic.
• Give oral antibiotics for 7 to 10 days.
• Ask the client to return after taking all antibiotics if the infection does not clear. If infection has not cleared, remove the implants or refer for removal.
• Expulsion or partial expulsion often follows infection. Ask the client to return if she notices an implant coming out.

Abscess (pocket of pus under the skin due to infection)
• Clean the area with antiseptic.
• Cut open (incise) and drain the abscess.
• Treat the wound.
• Give oral antibiotics for 7 to 10 days.
• Ask the client to return after taking all antibiotics if she has heat, redness, pain, or drainage of the wound. If infection is present when she returns, remove the implants or refer for removal.

Expulsion (when one or more implants begins to come out of the arm)
• Rare. Usually occurs within a few months of insertion or with infection.
• If no infection is present, replace the expelled rod or capsule through a new incision near the other rods or capsules, or refer for replacement.

Severe pain in lower abdomen (suspected ectopic pregnancy or enlarged ovarian follicles or cysts)
• Many conditions can cause severe abdominal pain. Be particularly alert for additional signs or symptoms of ectopic pregnancy,which is rare but can be life-threatening.

• In the early stages of ectopic pregnancy, symptoms may be absent or mild, but eventually they will become severe. A combination of these signs or symptoms should increase suspicion of ectopic pregnancy:
– Unusual abdominal pain or tenderness
– Abnormal vaginal bleeding or no monthly bleeding—especially if this is a change from her usual bleeding pattern
– Light-headedness or dizziness
– Fainting

• If ectopic pregnancy or other serious health condition is suspected, refer at once for immediate diagnosis and care.

• Abdominal pain may be due to other problems, such as enlarged ovarian follicles or cysts.
– A woman can continue to use implants during evaluation.
– There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. Reassure the client that they usually disappear on their own. To be sure the problem is resolving, see the client again in 6 weeks, if possible.

New Problems That May Require Switching Methods

May or may not be due to method.

Unexplained vaginal bleeding (that suggests a medical condition not related to the method)
• Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.

• If no cause of bleeding can be found, consider stopping implants to make diagnosis easier. Provide another method of her choice to use until the condition is evaluated and treated (not progestin-only injectables, or a copper-bearing or hormonal IUD).

• If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using implants during treatment.

Starting treatment with anticonvulsants or rifampicin
• Barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, and rifampicin may make implants less effective. If using these medications long-term, she may want a different method, such as monthly injectables, progestin-only injectables, or a copper-bearing or hormonal IUD.

• If using these medications short-term, she can use a backup method along with implants.

Migraine headaches
• If she has migraine headaches without aura, she can continue to use implants if she wishes.
• If she has migraine aura, remove the implants. Help her choose a method without hormones.

Certain serious health conditions (suspected blood clots in deep veins of leg or lungs,liver disease,or breast cancer).
• Remove the implants or refer for removal.
• Give her a backup method to use until her condition is evaluated.
• Refer for diagnosis and care if not already under care.

Heart disease due to blocked or narrowed arteries (ischemic heart disease) or stroke
• A woman who has one of these conditions can safely start implants. If, however, the condition develops while she is using implants:
– Remove the implants or refer for removal.
– Help her choose a method without hormones.
– Refer for diagnosis and care if not already under care.

Suspected pregnancy
• Assess for pregnancy, including ectopic pregnancy.
• Remove the implants or refer for removal if she will carry the pregnancy to term.
• There are no known risks to a fetus conceived while a woman has implants in place.

Questions and Answers About Implants

1. Do users of implants require follow-up visits?

No. Routine periodic visits are not necessary for implant users. Annual visits may be helpful for other preventive care, but they are not required. Of course, women are welcome to return at any time with questions.

2. Can implants be left permanently in a woman’s arm?

Leaving the implants in place beyond their effective lifespan is generally not recommended if the woman continues to be at risk of pregnancy. The implants themselves are not dangerous, but as the hormone levels in the implants drop, they become less and less effective.

3. Do implants cause cancer?

No. Studies have not shown increased risk of any cancer with use of implants.

4. How long does is take to become pregnant after the implants are removed?

Women who stop using implants can become pregnant as quickly as women who stop nonhormonal methods. Implants do not delay the return of a woman’s fertility after they are removed. The bleeding pattern a woman had before she used implants generally returns after they are removed. Some women may have to wait a few months before their usual bleeding pattern returns.

5. Do implants cause birth defects? Will the fetus be harmed if a woman accidentally becomes pregnant with implants in place?

No. Good evidence shows that implants will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while using implants or accidentally has implants inserted when she is already pregnant.

6. Can implants move around within a woman’s body or come out of her arm?

Implants do not move around in a woman’s body. The implants remain where they are inserted until they are removed. Rarely, a rod may start to come out, most often in the first 4 months after insertion. This usually happens because they were not inserted well or because of an infection where they were inserted. In these cases, the woman will see the implants coming out. Some women may have a sudden change in bleeding pattern. If a woman notices a rod coming out, she should start using a backup method and return to the clinic at once.

7. Do implants increase the risk of ectopic pregnancy?

No. On the contrary, implants greatly reduce the risk of ectopic pregnancy. Ectopic pregnancies are extremely rare among implant users. The rate of ectopic pregnancy among women with implants is 6 per 100,000 women per year. The rate of ectopic pregnancy among women in the United States using no contraceptive method is 650 per 100,000 women per year.

On the very rare occasions that implants fail and pregnancy occurs, 10 to 17 of every 100 of these pregnancies are ectopic. Thus, the great majority of pregnancies after implants fail are not ectopic. Still, ectopic pregnancy can be life-threatening, so a provider should be aware that ectopic pregnancy is possible if implants fail.

8. Do implants change women’s mood or sex drive?

Generally, no. Some women using implants report these complaints. The great majority of implant users do not report any such changes, however, and some report that both mood and sex drive improve. It is difficult to tell whether such changes are due to the implants or to other reasons. There is no evidence that implants affect women’s sexual behavior.

9. Should heavy women avoid implants?

No. These women should know, however, that they need to have Jadelle or Norplant implants replaced sooner to maintain a high level of protection from pregnancy. In studies of Norplant implants pregnancy rates among women who weighed 70-79 kg were 2 per 100 women in the sixth year of use. Such women should have their implants replaced, if they wish, after 5 years. Among women who used Norplant or Jadelle implants and who weighed 80 kg or more, the pregnancy rate was 6 per 100 in the fifth year of use. These women should have their implants replaced after 4 years. Studies of Implanon have not found that weight decreases effectiveness within the lifespan approved for this type of implant.

10. What should be done if an implant user has an ovarian cyst?

The great majority of cysts are not true cysts but actually fluid-filled structures in the ovary (follicles) that continue to grow beyond the usual size in a normal menstrual cycle. They may cause some mild abdominal pain, but they only require treatment if they grow abnormally large, twist, or burst. These follicles usually go away without treatment.

11. When will Norplant implants no longer be available?

The manufacturer intends to produce Norplant implants until 2011 and expects to replace Norplant with a newer product, Jadelle. Jadelle implants are similar to Norplant. Jadelle is easier and faster to insert and remove because it has only 2 rods, compared with Norplant’s 6 capsules. One study found that providers can easily switch from providing Norplant to providing Jadelle. They preferred the greater ease of inserting and removing Jadelle.

12. Can a woman work soon after having implants inserted?

Yes, a woman can do her usual work immediately after leaving the clinic as long as she does not bump the insertion site or get it wet.

13. Must a woman have a pelvic examination before she can have implants inserted?

No. Instead, asking the right questions can help the provider be reasonably certain she is not pregnant. No condition that can be detected by a pelvic examination rules out use of implants.