INFO Project- Implants: Tools for Providers

Publication date: 2007

Implants: Tools for Providers October 2007 • Issue No. 15 INFO Project Center for Communication Programs Counseling Clients About Implants Women consider effectiveness the most important factor when they choose a contraceptive method, but also consider side effects and safety (1, 5, 14, 15). Counseling helps a woman decide if a method suits her needs, preferences, and current situation. During counseling, family planning providers can ensure that women interested in implants understand their effectiveness and side effects, are assured of their safety, and know how they are used. Providers can use the information in this table to inform women about implants and help them make decisions. Key Points: Give Women This Information See companion Population Reports, “Implants: The Next Generation“ Implants: Are one of the most effective contraceptive methods.• Are small flexible rods or capsules that are placed just under the skin • of the upper arm. Are barely visible but can be felt under the skin.• Require a specifically trained provider to insert and remove. A woman • cannot start or stop using implants on her own. Will hurt a bit to have inserted and probably a bit more to have • removed. The procedure may leave a small visible scar. May change her monthly bleeding pattern. These changes are • common and are not harmful. Provide long-term protection from pregnancy. Very effective for 3 to 5 • years, depending on the type of implant. (Explain when she will need her implant replaced.) Do not affect future fertility. Fertility returns • immediately after implants are removed. Provide no protection against sexually • transmitted infections (STIs), including HIV. (Continued on page 3) Women need this information to make informed choices about implants 2 This report was prepared by Ushma D. Upadhyay, PhD, MPH and Deepa Ramchandran, MHS. Research assistance by Lauren Necochea, MPA. Ward Rinehart, Editor. Francine Mueller and Linda Sadler, Designers. The INFO Project appreciates the assistance of the following reviewers: Maaike Addicks, Vivian Brache, Gloria Coe, Carmela Cordero, Peggy D’Adamo, Juan Díaz, Laneta Dorflinger, Stephen Goldstein, David Hubacher, Barbara Janowitz, Monica Jasis, Enriquito Lu, Olav Meirik, J.T. Mutihir, Nuriye Ortayli, Frank Roijmans, J. Joseph Speidel, Pauline Russell-Brown, Markus Steiner, and Vera Zlidar. Suggested citation: Upadhyay, U.D. and Ramchandran, D. “Implants: Tools for Providers.” INFO Reports, No. 15. Baltimore, Johns Hopkins Bloomberg School of Public Health, The INFO Project, October 2007. Available online at: http://www.infoforhealth.org/inforeports/ The INFO Project Center for Communication Programs Johns Hopkins Bloomberg School of Public Health 111 Market Place, Suite 310 Baltimore, MD 21202 USA 410-659-6300 410-659-6266 (fax) www.infoforhealth.org infoproject@jhuccp.org Earle Lawrence, Project Director Theresa Norton, Associate Editor Rafael Avila, Production Manager INFO Reports is designed to provide an accurate and authoritative report on important developments in family planning and related health issues. The opinions expressed herein are those of the authors and do not necessarily re- flect the views of the U.S. Agency for International Development or the Johns Hopkins University. Published with support from USAID, Global, GH/PRH/PEC, under the terms of Grant No. GPH-A-00-02-00003-00. How to Use This Report Family planning providers can use the checklists and tables in this report to: Counsel clients about implants (see pp. 1 and 3)• Identify women who may not be able to use implants for medical reasons • (see Checklist, p. 4) Review the steps for appropriate infection prevention during insertion and removal of • implants (see Checklist, p. 5–6) Counsel women about changes in monthly bleeding (see p. 7)• Review the insertion and removal steps for new implants (see pp. 8–9)• Answer questions about implants (see Q&A, pp. 10–11)• This report accompanies Population Reports, “Implants: The Next Generation.” It also complements the information provided in the chapter on implants in Family Planning: A Global Handbook for Providers, available at: http://www.fphandbook.org. To request print copies contact: Orders, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202, USA (E-mail: orders@jhuccp.org). Photo on Cover At the PROFAMILIA Clinic in Santo Domingo, Dominican Republic, a family planning provider locates the implants in a woman’s arm before removing them. ©2007 Jose Miguel Renville New contraceptive implants are becoming available to family planning programs around the world—the one-rod system Implanon®, the two- rod system Jadelle®, and in some countries Sino-Implant (II)®, also two rods (not shown). By 2008 Norplant®, the six-capsule implant system, will no longer be available. Generally, counseling and screening clients is the same as for Norplant but providers will need training in insertion and removal procedures to offer the new implants. © 20 06 D av id A le xa nd er , C ou rte sy o f P ho to sh ar e © 20 06 D av id A le xa nd er , C ou rte sy o f P ho to sh ar e 3 Among• Far less than 1 pregnancy per 100 women using implants over the first year.• A small risk of pregnancy remains beyond the first year of use and continues as long as the • woman is using implants. Thicken cervical mucus. This blocks sperm from meeting an egg.• Disrupt the menstrual cycle, including preventing the release of eggs from the ovaries • (ovulation). Do not interrupt an existing pregnancy or interfere with implantation. • Implanon• : As labeled, 3 years after insertion. Jadelle• : As labeled, 5 years after insertion. If the woman weighs over 80 kg, she can consider having Jadelle replaced 4 years after insertion to maintain greatest effectiveness, especially if she is less than 30 years old. Sino-Implant (II)• : As labeled, 4 years after insertion. Norplant• : As labeled, 5 years after insertion. If the woman weighs less than 70 kg, Norplant provides good contraceptive protection for up to 7 years. If the woman weighs 70–79 kg, she can consider having Norplant replaced 5 years after insertion. If she weighs over 80 kg, she can consider having Norplant replaced 4 years after insertion, especially if she is less than 30 years old. Fertility returns immediately after the implants are removed. Women who stop using • implants can become pregnant as quickly as women who stop using nonhormonal methods. 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. Effectiveness Key Message How effective? How implants prevent pregnancy Side Effects Known Health Benefits and Health Risks The most common side effect is changes in bleeding patterns. These changes are usually • not harmful and not signs of illness. Changes in bleeding patterns during the first year of use include lighter bleeding and fewer • days of bleeding, irregular bleeding that lasts more than 8 days, infrequent bleeding, and no monthly bleeding. In the first few months• of use, Implanon users are more likely than users of Norplant, Jadelle, or Sino-Implant (II) to have infrequent or no monthly bleeding and less likely to have frequent bleeding. Typical bleeding changes after about 1 year of use include lighter bleeding and fewer days • of bleeding, irregular bleeding, and infrequent bleeding. Some users report headaches, abdominal pain, acne (can improve or worsen), weight • change, breast tenderness, dizziness, mood changes, and nausea. Implants help protect against the risks of pregnancy and symptomatic pelvic inflammatory • disease. They may also help protect against iron-deficiency anemia. 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).• Expulsion of implant (expulsions most often occur within the first 4 months after insertion).• Source: World Health Organization and Johns Hopkins Bloomberg School of Public Health 2007 (17) When users should return to have implants removed or replaced Return to fertility Key Message Changes in monthly bleeding Other side effects Health benefits Health risks or complications Counseling Clients About Implants (continued) the most effective methods, like intrauterine devices, female sterilization, and vasectomy. 4 Medical Eligibility Criteria Checklist 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. Be sure to explain the health benefits and risks and the side effects of implants. Also, point out any conditions that would make using implants inadvisable, when relevant to the client. 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 evaluation and possible 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. These medications can make implants less effec- tive. 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. Examining table for the woman • to lie on and a support or adjoining side table for her arm Proper lighting• Antiseptic soap and water• Sterile surgical drapes• Clean tray• One pair of sterile (or high-level • disinfected) gloves Bowl of sterile or boiled water • to soak away talc on gloves (if not talc-free) Antiseptic solution poured in • a sterile (or high-level disinfected) bowl Sterile gauze and compresses• Local anesthetic, 5 ml syringe, • needle Implants (for insertion only) and • a sterile bowl in which to place the implants Scalpel with #11 blade (optional)• #10 trocar*• Forceps • Sterile skin bandage/closure• *Not needed for insertion of Implanon, which comes in a sterile insertion applicator. Adapted from: Chikamata 2002 (2) Do not use implants if: The implant’s sterile packaging is open or broken. One or more of the  capsules is missing or discolored (not white). One or more of the  capsules is broken or bent. Equipment for Inserting and Removing Implants 5 Checklist: Providing Implants, With Appropriate Infection Prevention Practices Although insertion and removal of implants are minor surgical procedures, careful infection prevention procedures must be followed with every client. Infection prevention during insertion and removal involves aseptic technique (performing the procedures under sterile conditions). Proper infection prevention procedures minimize the chances of blood-borne infections such as HIV and hepatitis B and of infections at the insertion site. Infection at the insertion site may require early removal or cause spontaneous expulsion of implants. Generally, sterilization is required for instruments such as scalpels and needles that touch tissue beneath the skin. If sterilization is not possible or practical, instruments must be high-level disinfected. Family planning providers can use this checklist to help ensure that the procedure is done safely: Getting Ready Have the client wash her entire arm and hand (the one she uses less often) with soap and water, and dry with clean  towel or air-dry. Cover the procedure table and arm support with a clean cloth. Ask the client to lie on her back on the table so that the arm in which the implants will be placed is turned outwards  and bent at the elbow and is well supported. Prepare a clean instrument tray and open the sterile instrument pack without touching the instruments or other items. For  Jadelle and Sino-Implant (II), carefully open the sterile pouch containing the implants by pulling apart the sheets of the pouch and, without touching the rods, allowing them to fall into a sterile cup or bowl. For  Implanon, remove the sterile applicator with the preloaded implant from the package by allowing it to fall on the sterile tray without touching it. Before Insertion Wash hands thoroughly with antiseptic soap and water and dry with clean towel or air-dry.  Put sterile or high-level disinfected gloves on both hands before each procedure. (If using gloves with powder, rinse  them in sterile or boiled water before starting the procedure because the powder may fall into the insertion site and cause scarring.) Clean the insertion site with a cotton or gauze swab soaked in antiseptic solution and held in a sterile or high-level  disinfected forceps. Use sterile surgical drape with a hole in it to cover the arm. The hole should be large enough to expose the entire  area where the implants will lie once they are inserted. (If sterile drape is not available, use a clean drape or linen that has been washed, dried, ironed, and stored in a clean closet.) When giving local anesthetic, use a new disposable syringe and needle, from a sealed package, if available. An auto- disable syringe is preferable. # # Implant Checklist for Providers Before inserting the implant, discuss these points with the client and check that she understands them.  We offer a variety of contraceptive methods, and you can choose the one you want.  It will hurt a bit to get the implant inserted and probably a bit more to get it removed.  The implant will change your bleeding pattern and probably will cause lighter bleeding and fewer days of bleeding, irregular bleeding that lasts more than 8 days, infrequent bleeding, and no monthly bleeding.  The insertion and removal procedures may bruise your arm and leave a small visible scar. T h is c h ec kl is t ca n b e d et ac h ed a n d p h o to co p ie d . 6 During Insertion Jadelle and Sino-Implant (II): To minimize risk of infection and/or expulsion, make sure that the ends of the rods nearest to  the incision are not too close (not less than 5 mm) to the incision. If the tip of the rod protrudes from or is too close to the incision, it should be carefully removed and reinserted in the proper position. Also, to enable easy removal of both rods from a single incision, it is important that the ends of the rods closest to the incision are not farther apart, one from the next, than the width (not length) of one implant. While inserting the implants, try not to remove the trocar from the incision. Keeping the trocar  in place minimizes tissue trauma, decreases the chances of infection, and minimizes insertion time. Implanon: After confirming that the rod is in the applicator, remove the needle shield. Without the needle  shield, the implant can fall out, so keep the applicator in the upright position until the moment of insertion. If it falls out or if contamination otherwise occurs, use a new package with a new sterile applicator. After Insertion Press down on the incision with gauze for a minute or so to stop any bleeding, and then clean  the area around the insertion site with antiseptic solution on a swab. Use an adhesive bandage or surgical tape with sterile cotton to cover the insertion site. Check  for any bleeding. Cover with a dry compress and wrap gauze around arm tight enough to provide some compression to minimize bleeding under the skin (hematoma), but not so tight that it will cause pain and paleness in the arm. Dispose of the single-use applicator (for  Implanon) and used disposable syringes and needles in a puncture-resistant container. Immediately after inserting or removing the  implants, decontaminate the trocar, scalpel, syringe and needle, and any other nondisposable instruments by soaking them in a 0.5% chlorine solution for 10 minutes. Decontamination makes them safer for final processing of the instruments (described below). Dispose of contaminated objects (gauze, cotton,  and other waste items) in a properly marked leak-proof container with a tight-fitting lid or in a plastic bag. If disposable gloves were used, carefully remove  gloves by inverting and place in the waste container. If reusable gloves were used, immerse both gloved hands briefly in the chlorine solution to  decontaminate the outside, and then remove the gloves by inverting. Clean instruments and gloves after they have soaked in the chlorine solution for 10 minutes  (as described above). Wash instruments with a brush, using water and either liquid soap or detergent. Avoid bar soap or powdered soap, which can stay on the equipment. Rinse and dry the equipment. While cleaning, wear utility gloves and an apron. Sterilize instruments and gloves in a high-pressure steam autoclave or a dry-heat oven or with  chemicals. If sterilization is not possible or practical, high-level disinfect them by boiling, by steaming, or with chemicals. Decontaminate all surfaces that could have been contaminated by blood, such as the  procedure table or instrument stand, by wiping them down with 0.5% chlorine solution. Wash hands with soap and water and dry with clean towel or air-dry. Sources: McIntosh 1993 (8), Organon 1999 (9), Organon 2005 (10), EngenderHealth 2001 (4), World Health Organization 2004 (16), and World Health Organization and Johns Hopkins Bloomberg School of Pubic Health 2007 (17) # © 20 05 D r. P hi lip pe F au ch er /P ar is 7 Tool: Counseling About Changes in Monthly Bleeding How to use this tool: Family planning providers can use information from the table below to explain the bleeding changes that new clients can expect. Concerns about bleeding changes deserve the provider’s attention. If a continuing user reports side effects or problems, listen to her concerns, give her advice, and, if appropriate, treat. Specific guidance for managing bleeding problems among implant users is available in the Implants chapter of Family Planning: A Global Handbook for Providers, available at: http://www.fphandbook.org Bleeding Changes Due to Implants — What Might Happen In the first year users may experience one or more of the following: After about one year users may experience one or more of the following: – Lighter bleeding and fewer days of bleeding – Irregular bleeding that lasts more than 8 days* – Infrequent bleeding – No monthly bleeding – Lighter bleeding and fewer days of bleeding – Irregular bleeding – Infrequent bleeding – Even at one year some women have no monthly bleeding *In the first few months Implanon users are more likely than users of Norplant, Jadelle, or Sino-Implant (II) to have infrequent or no monthly bleeding and less likely to have frequent bleeding. Users of all implants experience irregular bleeding lasting more than 8 days at similar rates. After 1 year there are no significant differences among the various implants. Norplant, Jadelle, and, Sino-Implant (II) users with lower body weight have fewer bleeding episodes (days of bleeding) and longer bleeding-free intervals than heavier women (12). Sources: Edwards 1999 (3), Hickey 2002 (7), Han 1999 (6), and Zheng 1999 (18) Implants for Women With HIV/AIDS 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. 8 Insertion and Removal of the New Implants Learning to insert and remove implants requires training and practice under direct supervision. Therefore, the following illustrations and description serve as a summary and not detailed instructions for providers. The instructions apply after providing anesthetic. Implanon insertion: Step 1. Mark the insertion site (where implant will be inserted). Stretch the skin around the insertion site with thumb and index finger. Step 2. Insert only the tip of the cannula (needle), slightly angled (about 20˚). Step 3. Lower the applicator to a horizontal position. Step 4. Lift the skin with the tip of the needle, but keep the needle in the subdermal connective tissue. Gently insert, while lifting the skin, the needle to its full length, and keep the applicator parallel to the surface of the skin. Step 5. Break the seal of the applicator. Step 6. Turn the obturator (the rounded end of the applicator) a quarter turn (90˚). Step 7. Fix the obturator with one hand against the arm, and with the other hand slowly draw the cannula (needle) out of the arm. 20 90 9 Jadelle and Sino-Implant (II) insertion: Step 1. Make a small incision with a scalpel or trocar in the skin on the inside of the upper arm. Alternatively, use the trocar to puncture the skin. Insert the tip of the trocar beneath the skin at a shallow angle. Gently advance the trocar superficially under the skin (not shown). Note: The trocar has three marks on it. The mark closest to the hub indicates how far the trocar should be introduced under the skin to place the Jadelle implants. The middle mark is not used. The mark closest to the tip indicates how much of the trocar should remain under the skin following placement of the first implant. Step 2. When the trocar has been inserted to the mark closest to the hub, remove the obturator and load the first implant into the trocar, using thumb and forefinger. Step 3. Using the obturator to push, gently advance the implant towards the tip of the trocar until you feel resistance. Never force the obturator. Step 4. Holding the obturator stationary, withdraw the trocar to the mark closest to the trocar tip. The implant should be released under the skin at this point. It is important to keep the obturator stationary and to avoid pushing the implant into the tissue. Do not completely remove the trocar until both implants have been placed. Step 5. To place the second implant, align the trocar so that the second implant will be positioned at about a 30˚ angle relative to the first implant. Repeat steps 3-4. The rods are placed in the shape of a V opening toward the shoulder. Leave a distance of about 5 mm between the incision and the tips of the implants. Remove the trocar. Implant removal: Step 1. Make an incision (4 mm for Jadelle and Sino-Implant (II) and 2 mm for Implanon) with the scalpel close to the proximal ends of the implants (below the bottom of the V for Jadelle and Sino-Implant (II), and below the single rod for Implanon). Do not make a large incision. Push each implant gently towards the incision with the finger. When the tip of the rod is visible, grasp it with the forceps and gently pull out the rod with the forceps. Repeat procedure for the second implant (Jadelle and Sino-Implant (II)). Sources: Organon 1999 (9), Organon 2005 (10), Population Council 2005 (11), Sivin 2002 (13), and World Health Organization 2007 (17) 10 Questions and Answers About Implants The New Implants What are the main differences among the different implants?1. The main differences are the number of capsules or rods, the type of progestin that each releases, and how long they can be used before replacement. Implanon: 1 rod containing 68 mg of etonogestrel. Labeled for 3 years of use. Sino-Implant (II): 2 rods, each containing 75 mg of levonorgestrel. Labeled for 4 years of use. Jadelle: 2 rods, each containing 75 mg of levonorgestrel. Labeled for 5 years of use. Norplant: 6 capsules, each containing 36 mg of levonorgestrel. Labeled for 5 years of use. (Large studies have found it is effective for 7 years.) When will 2. Norplant implants no longer be available? The manufacturer intends to produce Norplant implants until 2008 and then expects programs to replace Norplant with the newer product, Jadelle. Jadelle is already registered in over 50 countries. Providing Implants Can young women and older women use implants?3. Yes. There is no minimum or maximum age limit. Implants should be removed after menopause has occurred—12 months after a woman’s last monthly bleeding. Implants, like all other hormonal methods, affect bleeding, and so it may be difficult to know if a woman using them has reached menopause. After stopping a hormonal method, a woman can use a nonhormonal method. She no longer needs contraception once she has had no bleeding for 12 months in a row. Tip: Counselors in Indonesia have explained to their clients: “All women, even those  who are old, young, or don’t have children, can use implants safely and effectively. Implants will not cause negative effects to the body, and your fertility will return as soon as they are removed.” After Insertion Can a woman work soon after having implants inserted? 4. Yes, a woman can do her usual work immediately after leaving the clinic, as long as she tries not to bump the insertion site or get it wet for 4 days. What can be done about pain or soreness at the insertion or removal site?5. 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. Do users of implants need to make follow-up visits?6. No. Implant users do not need to make any routine follow-up visits. Annual visits may be helpful for other preventive care, but they are not required for use of implants. Of course, women should be invited to return at any time if they have questions or problems. Can implants be left permanently in a woman’s arm?7. 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 and should no longer be relied on to prevent pregnancy. Effectiveness How effective are implants compared with other family planning methods?8. Implants are among the most effective contraceptive methods—as effective as the IUD, female sterilization, and vasectomy. During the first year of implant use, less than one pregnancy is ex- pected per 100 women using implants (5 pregnancies per 10,000 users). This means that 9,995 of every 10,000 women using implants will not become pregnant in the first year. A small risk of pregnancy remains for as long as a woman continues to use implants. 11 Should heavy women avoid implants?9. No, heavier women can use implants, and the implants will be highly effective. These women should know, however, that the effectiveness of Jadelle or Norplant implants may start to drop off sooner than for other women. For example, in studies of Norplant implants, the pregnancy rate among women who weighed 70 to 79 kg was 2 per 100 women in the sixth year of use. Women who want to maintain maximum contraceptive effectiveness should consider having their implants replaced or removed at five years after insertion. 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 can consider having their implants replaced at four years after insertion, especially if they are less than 30 years of age. Keeping the implants in after four years will still offer these women better protection from pregnancy than many other methods. No studies of Implanon have found that effectiveness declines among heavier women within the 3-year lifespan approved for this type of implant. Side Effects What should be done if bleeding changes are bothering a user of implants?10. In the first few months of use, explain that the changes probably will lessen with time. If the bleeding changes continue to bother the client, or if at any time a client asks, offer available treatments such as ibuprofen, mefenamic acid, or oral contraceptives, which may provide some short-term relief from the bleeding changes (see “Counseling About Changes in Monthly Bleeding,” p. 7). At any time a client finds bleeding changes unacceptable, help her choose a method that better suits her. Tip: Providers in Egypt counsel their clients by explaining, “The most frequent side effect is disruption  of the menstrual cycle, including spotting between periods, amenorrhea, and prolonged bleeding. But, in general, the total monthly blood loss is less than in a normal menstrual period.” What should be done if an implant user has an ovarian cyst?11. The great majority of cysts are not true cysts but actually fluid-filled structures (follicles) in the ovary that continue to grow beyond the usual size in a normal menstrual cycle. They may cause some mild abdominal pain, but they require treatment only if they grow abnormally large, twist, or rupture (burst). Usually, these follicles go away without treatment. Health Issues Do implants cause cancer?12. No. Studies have shown no increased risk of any cancer with use of implants when compared with women not using any contraception. Can implants move around within a woman’s body or come out of her arm?13. 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 through the insertion site, most often in the first four months after insertion. When this happens, it is usually because the implants were not inserted well or because of an infection where they were inserted. In these cases the woman will see the implants coming out. Also, some women may have a sudden change in bleeding pattern, which could indicate that a rod has come out. If a woman notices a rod coming out, she should start using a backup contraceptive method and return to the clinic as soon as possible. Tip: Counselors in Indonesia use this message to counsel clients: “Implants will be inserted under the  skin on your arm and will not travel to other parts of your body because your skin tissues will keep them in place. Implants contain progesterone hormones that will influence your reproductive organs and therefore they do not cripple your arm or reduce the strength of your hand.” Do implants increase the risk of ectopic pregnancy?14. 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. By comparison, 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. Do implants cause birth defects? Will the fetus be harmed if a woman accidentally becomes pregnant with 15. implants in place? No. There is good evidence to show that implants will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while using implants or she accidentally has implants inserted when she is already pregnant. Adapted from: World Health Organization and Johns Hopkins Bloomberg School of Public Health, 2007 (17) 12 Subscribing to INFO Reports There are three ways that you can make sure to receive ALL future issues of INFO Reports: 1. 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Alternatively, write to: Orders, INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202, USA. 3. By the INFO Web site: Go to http://www.infoforhealth.org/ inforeports/infoelectsub.php and follow instructions for subscribing. Please Note: If you do not want to subscribe but wish to order INDIVIDUAL issues of INFO Reports and other publications from the INFO Project, Johns Hopkins Bloomberg School of Public Health, please send an e-mail message to: orders@jhuccp.org, or go to our online order form at: http//www.jhuccp.org/orders/, or write to Orders, INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202, USA. Sources The links included in this report were up- to-date at the time of publication. This bibliography includes citations to the materials most helpful in the preparation of this report. 1. BRUCE, J. Fundamental elements of the quality of care: A simple framework. Studies in Family Planning 21(2): 61-91. Mar.-Apr. 1990 2. CHIKAMATA, D.M. and MILLER, S. Health services at the clinic level and implantable contraceptives for women. Contraception 65(1): 97-106. Jan. 2002. 3. EDWARDS, J.E. and MOORE, A. Implanon. A review of clinical studies. British Journal of Family Planning 24(4 Suppl.): 3-16. Jan. 1999. 4. ENGENDERHEALTH. Infection prevention: A reference booklet for health care practitioners. New York, EngenderHealth, 2001. 75 p. (Available: http://www. engenderhealth.org/res/offc/safety/ip-ref/pdf/ip-ref-eng. pdf) 5. FOLCH-LYON, E., DE LA MACORRA, L., and SCHEARER, S.B. Focus group and survey research on family planning in Mexico. Studies in Family Planning 12(12 Pt 1): 409-432. Dec. 1981. 6. HAN, L., FAN, H., GONG, Q., XIE, Z., MENG, F., HONG, Y., and WANG, W. Effects of three types of long- acting contraceptive implants on menstrual blood loss in 89 women. Reproduction and Contraception 10(2): 91-97. 1999. 7. HICKEY, M. and D’ARCANGUES, C. Vaginal bleeding disturbances and implantable contraceptives. Contraception 65(1): 75-84. Jan. 2002. 8. MCINTOSH, N., RISEBOROUGH, P., and DAVIS, C., eds. Norplant® guidelines for family planning service programs: A problem-solving reference manual. Baltimore, JHPIEGO, Jan. 1993. 9. ORGANON. Implanon® Clinician’s Manual. 1999. 64 p. 10. ORGANON. Implanon® Product Monograph. 2005. 84 p. 11. POPULATION COUNCIL. «Norplant® II» levonorgestrel implants (Jadelle®). New York, 2005. 50 p. (Available: http://www.popcouncil.org/licensing/20544se2- 003_jadelle_lbl.pdf) 12. SIVIN, I. Risks and benefits, advantages and disadvantages of levonorgestrel-releasing contraceptive implants. Drug Safety 26(5): 303-335. 2003. 13. SIVIN, I., NASH, H., and WALDMAN, S. Jadelle® levonorgestrel rod implants: A summary of scientific data and lessons learned from programmatic experience. New York, Population Council, 2002. 48 p. (Available: http://list. popcouncil.org/pdfs/jadelle_monograph.pdf) 14. STEINER, M.J., TRUSSELL, J., MEHTA, N., CONDON, S., SUBRAMANIAM, S., and BOURNE, D. Communicating contraceptive effectiveness: A randomized controlled trial to inform a World Health Organization family planning handbook. American Journal of Obstetrics and Gynecology 195(1): 85-91. Jul. 2006. 15. THORN, N.T., HIEU, D.T., NHAN, V.Q., NHAN, D.T., WHITTAKER, M., FAJANS, P., and SATIA, J. The strategic approach to the introduction of DMPA as an opportunity to improve quality of care for all contraceptive methods in Viet Nam. Asia-Pacific Population Journal 15(4): 63-88. Dec. 2000. 16. WORLD HEALTH ORGANIZATION (WHO), REGIONAL OFFICE FOR SOUTH-EAST ASIA, and REGIONAL OFFICE FOR WESTERN PACIFIC. Practical guidelines for infection control in health care facilities. World Health Organization, 2004. 103 p. (Available: http:// www.wpro.who.int/NR/rdonlyres/006EF250-6B11-42B4- BA17-C98D413BE8B8/0/practical_guidelines_infection_ control.pdf) 17. WORLD HEALTH ORGANIZATION DEPARTMENT OF REPRODUCTIVE HEALTH AND RESEARCH (WHO/ RHR) and JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH/CENTER FOR COMMUNICATION PROGRAMS (CCP). Family planning: A global handbook for providers. Baltimore and Geneva, CCP and WHO, 2007. (Available: www.fphandbook.org) 18. ZHENG, S.R., ZHENG, H.M., QIAN, S.Z., SANG, G.W., and KAPER, R.F. A long-term study of the efficacy and acceptability of a single-rod hormonal contraceptive implant (Implanon) in healthy women in China. European Journal of Contraception and Reproductive Health Care 4(2): 85-93. Jun. 1999. Illustrations by Rafael Avila To order the companion Population Reports, “Implants: The Next Generation”: Please send an e-mail message to: orders@jhuccp.org, or go to our online order form at: http//www.jhuccp.org/orders/ or write to: Orders, INFO Project, Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health,111 Market Place, Suite 310, Baltimore, MD 21202, USA. Tool: Implant Reminder Card Providers can copy and cut out this sample reminder card to give to clients. Alternatively, providers or clinic managers can tailor it by adding any new lines that are needed. # # # #

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