Experience with contraceptive implants: removal technique classification of difficulties and the importance of correct placement.

The successful use of Norplant in family planning programs requires that doctors and nurses are thoroughly trained in insertion and removal techniques and have good counseling skills. The International Planned Parenthood Federation recommends 5-10 supervised Norplant insertions and 3-5 removals for certification. Preferred for removal is the "U" technique that utilizes a special ring forceps to grasp the capsules. If the capsules are placed too deeply broken or not aligned in a fan shape removal will be problematic. Approved by the Expert Group Meeting on Norplant held in Leeds England in November 1994 is a three-tiered removal classification system. In Group A (simple) removals the capsules are well placed subdermal and palpable. Removal time is less than 20 minutes and one 4 mm incision is sufficient; less than 5 mg of 1% lignocaine is used for anesthesia. In Group B (difficult) removals implants are palpable but misaligned. One 4 mm incision and up to 10 ml of 1% lignocaine are recommended; surgical time is less than 40 minutes. In Group C (complicated) removals capsules are misplaced or misaligned and difficult to palpate. A second incision less than 1 cm and multiple injections of local or general anesthesia may be required. X-ray or ultrasound may be necessary to locate implants and removal can take up to 60 minutes. Given an implant removal rate of only 10% per year not all trained inserters gain sufficient removal experience. To prevent two-staged removals it is recommended that physicians refer all difficult and complicated removals to experienced removal experts at regional centers.