Introduction
Implanon is single-rod etonogestrel progestin implant approved for use in the United States in 2006. As of April 2007, Implanon is currently marketed in more than 30 countries with approximately 2.5 million implants inserted since its inception in 1998.
The rod is effective for up to 3 years. It is inserted using a preloaded, sterile, single-use applicator. The Implanon is inserted subdermally in the inner aspect of the nondominant upper arm. The rod is placed in the groove between the biceps and triceps in the sulcus bicipitalis medialis. It is easily accessible but not easily seen.
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The Implanon rod is 4 cm in length and 2 mm in diameter. It is composed of a solid core of ethylene vinyl acetate (EVA) with crystals of etonogestrel (ENG) imbedded within the core. The rod contains 68 mg of etonogestrel releasing 60 to 70 Όg/day initially, which decreases to 40 to 45 Όg/day after a few weeks and then decreases to 25 to 30 Όg/day by the end of the third year. Implanon is not radio-opaque and therefore cannot be seen on x-ray or computer tomography (CT) scans. It is easily detectable by ultrasound using a high-frequency linear-array transducer or by magnetic resonance imagery (MRI).
Six pregnancies have been reported in 20,648 cycles of Implanon use, with a cumulative Pearl Index of 0.38 pregnancies per 100 woman years of use. The effectiveness of Implanon in overweight women was not evaluated in the original studies, as women heavier than 130% of their ideal body weight were not included. Serum concentrations of etonogestrel (ENG) are inversely related to body weight and decrease with time after insertion; therefore it is possible that with time Implanon may be less effective in overweight women.
Implanon works by two main mechanisms: inhibition of ovulation and increased viscosity of cervical mucus. It is quickly reversible, with undetectable serum concentrations of etonogestrel noted within the first week of removal. Return to ovulation within 3 months of removal occurs in more than 90% of women.
The most common side effect seen in women with Implanon is bleeding. It is crucial that women be counseled prior to insertion that spotting and bleeding will occur. The total number of bleeding and spotting days is similar to or better than what most women have with normal menstrual cycles; however, it is more irregular and less predictable. Dysmenorrhea improves significantly with Implanon. Other side effects include weight gain (2.3%), emotional lability (2.3%), headache (1.6%), acne (1.3%), and depression (1.0%). Most discontinuations occur within the first year as a result of bleeding or spotting. No significant effects have been noted in breastfeeding women with either production of breast milk or growth and development of infants.
Timing of insertion is crucial.
- If no preceding hormonal contraceptive use in the past month, insert during days 1 to 5 of the menstrual cycle.
- If switching from combination methods, insert anytime during the 7 days of the last active combined dose.
- Any day when switching from a progestin-only pill (do not skip any dose).
- Same day as implant or intrauterine system is removed.
- On the day when the next contraceptive injection would be due.
- Within 5 days following a first trimester abortion.
- Between 3 to 4 weeks following childbirth or second trimester abortion.
- After the fourth postpartum week if exclusively breastfeeding.
A back-up method of contraception is not needed if insertion occurs as described. If deviating from the recommended timing of insertion, rule out pregnancy and use a back-up method of contraception for 7 days after Implanon is inserted.
Equipment
- Sterile drapes
- Antiseptic swabs
- Gauzes, 2 2 inches
- Alcohol pad
- Syringe (3 cc) with 1% " lidocaine
- No. 11 scalpel
- Pressure dressing
- Adhesive bandage
- Surgical pen
- Tape measure
- Implanon device
Indications
- Any woman desiring long-acting, reversible contraception
- Smoking women older than age 35 who desire contraception
- Women who desire contraception but have a contraindication to use of estrogen
Contraindications
- Known or suspected pregnancy
- Current or past history of thrombotic disease
- Hepatic tumors or active liver disease
- Undiagnosed abnormal genital bleeding
- Known, suspected, or history of breast cancer
- Hypersensitivity to any of the components of Implanon
It is not recommended for women who require chronic use of drugs that are potent inducers of hepatic enzymes.
Contraceptive effectiveness may be reduced when co-administered with antibiotics, antifungals, anticonvulsants, and any drugs that increase the metabolism of contraceptive steroids
It is unknown whether anti-HIV protease inhibitors affect Implanon.
Herbal products containing St. John 's wort may reduce effectiveness.
The Procedure
Implanon Insertion
Step 1
The patient should be properly counseled and provided with the appropriate patient education materials. The patient package insert with consent form should be reviewed. Check the expiration date on the Implanon package. Place the patient in a supine position with her nondominant arm flexed at the elbow and externally rotated.
Step 1 View Original Step 1 View Original
Step 2
Identify the insertion site, which is 6 to 8 cm above the elbow crease at the inner side of the arm overlying the groove between the biceps and triceps. Mark the insertion site and make a second mark 6 to 8 cm above the first.
Step 2 View Original Step 2 View Original
Step 3
Clean the insertion site with povidone-iodine or chlorhexidine solution, and then inject a small amount of anesthetic just under the skin along the planned insertion canal. Raise a small weal, then inject the full distance where the rod will be inserted.
Step 3 View Original Step 3 View Original
Step 4
Carefully remove the Implanon sterile applicator from its blister pack. Keep the tip of the applicator up in order to keep the Implanon rod within the applicator. Identify the tip of the rod.
Step 4 View Original Step 4 View Original
Step 5
Gently tap the reverse end of the applicator to ensure that the entire rod is back within the applicator.
Step 5 View Original Step 5 View Original
Step 6
Stretch the skin at the insertion site with the thumb and index finger of your nondominant hand. Insert the needle tip, beveled side up, no greater than a 20-degree angle just until the skin has been penetrated.
Step 7
Once the tip is inserted, the applicator should be lowered to the horizontal plane. Lift or tent the skin with the tip of the needle while gently inserting the needle to its full length.
Step 8
Break the seal of the applicator by pressing the obturator support and turn the obturator 90 degrees in either direction with respect to the cannula. Fix or hold the obturator in place on the patient 's arm with your nondominant hand. Using your other hand, slowly retract the needle (cannula) back along the full length of the obturator.
Step 9
Check the obturator and look for the grooved tip visible inside the needle opening.
Step 9 View Original Step 9 View Original
Step 10
Palpate the implant to verify it is in the correct position. Have patient palpate the implant as well to confirm its position.
Step 11
Place a small Steri-strip over the insertion site, and then place an adhesive bandage over the area. Place a pressure bandage with sterile gauze. Patient should leave dressing in place for 24 hours. Fill out the user card and patient chart label and affix to the patient chart. Give the user card and personal calendar (bleeding diary) to the patient with instructions on keeping track of her bleeding.
Step 11 View Original Step 11 View Original
Implanon Removal
Step 1
Locate the implant by palpating the arm and mark the end closest to the elbow. Clean the area with antiseptic solution. Inject a small but sufficient amount of 1% " lidocaine just underneath the base of the implant (usually 0.5 cc is enough).
Step 2
Press down on the end of the implant closet to the axilla. Make a 2 to 3 mm incision in the arm (in a longitudinal direction) at the tip of the implant near the elbow. (The incision should be made at the tip of the implant and extend just below it.)
Step 2 View Original Step 2 View Original
Step 3
Gently push the implant toward the incision until the tip is visible. Grasp the implant with a mosquito forceps and gently pull out.
Step 4
If the tip is not visible after gently pushing it toward the incision, insert a curved forceps into the incision and grasp the implant.
Step 4 View Original Step 4 View Original
Step 5
Flip the forceps and use a second pair of forceps to localize the implant and dissect the capsule off the implant, then gently remove. If another Implanon is desired, a new implant can be placed in the same arm through the same incision. Close the incision with a Steri-strip and apply an adhesive bandage. Place gauze with a pressure dressing over the incision.
Step 5 View Original Step 5 View Original
Complications
- Deep insertion: difficult localization and removal
- Mistimed insertion: pregnancy
- Broken/bent implant: difficult removal
- Multiple insertions: increased risk of side effects
- Noninsertion: pregnancy
- Bleeding/spotting
- Infection
- Bruising
Pediatric Considerations
Progestin-only contraceptive methods are preferred methods for breastfeeding women. The effect of Implanon with breastfeeding has been studied in a nonrandomized group comparative study with copper IUD and Implanon. Approximately 0.2% of the maternal dose of etonogestrel is excreted in the breast milk. There was no change in the length of time breastfeeding or the quantity of breast milk in either group. There is no data on bone mass in adolescents to date.
Postprocedure Instructions
The provider should instruct the patient to leave the pressure dressing in place for 24 hours. Minimal pain is usually associated with insertion, but the patient can be instructed to use acetaminophen or ibuprofen if needed. No back-up method is necessary if inserted at the appropriate time of the cycle.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 11981 Insertion, nonbiodegradable drug delivery implant $335.00 XXX 11982 Removal, nonbiodegradable drug delivery implant $364.00 XXX 11983 Removal, with reinsertion, nonbiodegradable drug delivery implant $520.00 XXX 11975 Insertion, implantable contraceptive capsules $333.00 11976 Removal, implantable contraceptive capsules $366.00 0 11977 Removal, with reinsertion, implantable contraceptive capsules $546.00 XXX XXX, global concept does not apply.CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
S-Code
Etonogestrel implant, 68 mg $653.75
Some offices use the 11981 " 83 codes, whereas others use 11975 " 77 depending on the type of office setting.
The kit cost $523.00 direct to the provider and $675.00 for patient acquisition via a prescription at a pharmacy.
Diagnosis Codes
View Large V25.5 Encounter for contraceptive management, insertion of implantable subdermal contraceptive V25.43 Encounter for contraceptive management, surveillance of previously prescribed contraceptive method (checking, reinsertion, or removal of contraceptive device), implantable subdermal contraceptive V48.52 Other postprocedural states, presence of contraceptive device subdermal contraceptive implant
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2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
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