Title: Implanon
Course: Family Planning - Ethiopia (Full)

Implanon

Implanon is a single-rod contraceptive implant prepared from another type of progestin, which gives effective protection for three years (Figure 6.7). It looks like a small flexible plastic matchstick. It can be inserted into the arm following a simple procedure, similar to an injection, and you do not need to make an incision as with other implants. Implanon is the best option for women who have had one or more children, or who may want children in the future. It has been introduced for use in Ethiopia, and has been approved by the Ministry of Health to be provided by you at health post level, once you have been given proper training.

Figure 6.7 Sample implanon. (Source: Family Planning: A Global Handbook for Providers, WHO, 2007 p.119)

Wozero Misgane has two children and works hard on her land. She recently asked you for advice on the most suitable contraceptive method for her. She explained to you that she is worried about the side-effects, that she might want more children again in the future, and that she works hard on her farm, so she needs a contraceptive that does not make her weak.

What would you advise for Wozero Misgane?

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You may recommend Implanon for her as it is used by many women like her in Ethiopia and tell her that once it is removed she will be able to become pregnant.

W/ro Misgane decided to have the Implanon rod insertion. Six months later she told other women in her neighbourhood that it was the right contraceptive method for a rural hard-working woman like herself because she has had no side-effects and she has continued working hard without any ill effect.

How implants work

The mechanism of action of implants is similar to progesterone-only oral contraceptive pills and injectables, regardless of their route and duration of effectiveness.

How do implants prevent pregnancy?

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Implants have the following effects:

- They stop the release of the egg from the ovary by slowly releasing progestin (an artificial progestrone) into the client's body.
- The progestin in implants causes thickening of the cervical mucus, which makes it harder for sperm to move through the cervix.
- The progestin also causes thinning of the endometrial lining, making it less likely that a fertilised egg will implant in the uterus.
- Progestin slows the transportation of eggs along the fallopian tube by reducing peristalsis.

Effectiveness of contraceptive implants

Implants are more than 99.9% effective when they are inserted correctly (WHO, 2007). This means that less than one woman in 1,000 will get pregnant in the first year of use. There is no reported difference in contraceptive effectiveness or continuation rates among users of the various types of contraceptive implants. However, the effectiveness of contraceptive implants quickly reduces if women weigh more than 70 kg. In this case the implant needs early replacement, as early as one year before the intended year.

Advantages

Implants are very effective when compared to other contraceptive methods, and are particularly useful for women who know they do not want to get pregnant for a while. Once the implant is in place, the client does not have to think about contraception for the period of the implant. It is also a good choice of method for women who can't use any contraceptive that contains oestrogen, and for women who find it difficult to regularly take a pill at the same time every day. For these reasons, its continuation rate is high.

Disadvantages

Figure 6.8 A trained Health Extension Practitioner inserting Implanon.

Implants require a trained provider (Figure 6.8) to insert and remove the rods. When the implant is first inserted into the upper arm, the woman may feel some bruising, tenderness or swelling at the insertion site. For most women, during the first year of implant, their menstrual cycle may become irregular, lighter, heavier or longer. This usually settles down after the first year. In some clients, periods stop completely (amenorrhoea), but this is not harmful. Your client should be aware of these issues before deciding to have the implant. As with other contraceptives, this method does not protect couples from STIs. In this case, the client is advised to use condoms, as well as having an implant.

In addition to the disadvantages listed above, side effects which are associated with the use of contraceptive implants include weight gain, nervousness, anxiety, nausea, vomiting, dizziness, dermatitis/rashes, abnormal or heavy growth of hair over the body (hirsutism), hair loss, headaches, depression and acne. Sometimes pain, itching, or infection at the site of the implant will occur.

Managing side-effects and problems with implants

Listen to your client's worries and complaints and treat her concerns accordingly, referring her for further help if needed. If the client wishes, it is always possible to change to another method. Side-effects are similar to those of progesterone-only injectable contraceptives (see Box 6.2), and can be managed as instructed in the earlier part of this study session.

Box 6.2 When implants should not be given

Implants should not be given to women who have:

- serious liver disease
- problems of blood clots
- unexplained vaginal bleeding
- and/or had breast cancer.

Timing of contraceptive implant insertion and removal

Implants can be inserted at any time during the menstrual cycle, preferably within seven days of menstruation or post-abortion. It can also be inserted six weeks after delivery if the mother is fully breastfeeding. Generally, it can be inserted at any time, providing it is possible to confirm that the woman is not pregnant.

Contraceptive implant insertion and removal requires special training and should only be practiced under direct supervision.

Implants can be removed:

- at any time during the menstrual cycle.
- at the end of five years of use for Norplant or Jadelle, or three years of use for Implanon, when their effectiveness drops after the intended years of use, and the risk of intrauterine and ectopic pregnancy may increase.
- if the client wishes, at any time it is possible to remove an implant after providing the necessary counselling.

The removal of an implant is not a very complicated procedure, but it does require special training and practice under direct supervision. Following removal of any implants, the level of hormonal prevention drops quickly, and the women's fertility returns within two to six months.