Clinical challenge with Implanon® removal: a case report

A 28-year-old woman attended the family planning clinic for removal of Implanon® and discussion of her future contraceptive options. The implant had been inserted elsewhere and was due to be removed 2 months earlier. She had been using a barrier method of contraception for the 2month duration. The patient did not want another implant. Her unhappiness with the method was due to weight gain (2 stones), mood swings and acne. She acknowledged that lifestyle changes, lack of exercise and unhealthy eating habits contributed partly to her weight gain. On examination of the left arm, the scar identifying the site of insertion was visualised. There was difficulty in palpating the distal end of the Implanon in the biceps/triceps groove because the proximal end was deep. The Implanon was not palpable along its entire length. The patient was counselled about the method of Implanon removal and the possibility of difficulty with removal as it appeared to be slightly deep. Prior to removal her contraceptive options were discussed and the combined contraceptive pill was recommended. An attempt was made to remove the Implanon after infiltration with local anaesthetic. This procedure was unsuccessful due to deep insertion of the implant and the patient’s subsequent weight gain. Following this, the patient was counselled and advised that it would be necessary to localise the implant with ultrasound imaging before proceeding to a second surgical attempt. An ultrasound appointment was arranged in 1 month’s time to allow the exploration site to heal. The patient was also prescribed the combined contraceptive pill. An ultrasound scan using a high-frequency linear array transducer (11 MHz) revealed the distal end of the Implanon to be situated 3 mm below the skin adjacent to the scar site with the proximal end localised 7.7 mm below the skin. The two ends of the Implanon were identified by its acoustic shadow and the exact position identified by an echogenic spot as seen in Figure 1. The full length of the Implanon in longitudinal view is seen in Figure 2 as a rod which is not lying parallel to the skin surface but at an angle. The patient was informed of the findings and another attempt at removal was undertaken. A transverse skin incision about 1 cm in length was made over the distal site of Implanon localisation that had been identified previously by ultrasound. Despite the combined effort of two trained colleagues, removal was unsuccessful and the patient was referred to the general surgeon for specialist opinion and implant removal.