The basis for successful use and subsequent removal of IMPLANON is a correct and carefully performed subdermal insertion of the single rod implant in accordance with the instructions. If the implant is placed improperly leading to deep location or migration, it will be more difficult to remove than a correctly placed subdermal implant.
All healthcare providers performing insertions and removals of IMPLANON must be trained prior to inserting or removing IMPLANON.
Information concerning the insertion and removal of IMPLANON will be sent upon request free of charge. Contact Merck at 1.877.IMPLANON (1-877-467-5266).
Prior to inserting IMPLANON, carefully read the instructions for insertion and removal as well as the full Prescribing Information .
Insert IMPLANON (etonogestrel implant) under aseptic conditions. The following equipment is needed for IMPLANON insertion:
An applicator and its parts are shown in the following diagrams.
Place IMPLANON subdermally. Both you and your patient should be able to feel IMPLANON under her skin after placement.
The procedure used for IMPLANON insertion is opposite from that of an injection. The obturator keeps IMPLANON in place while the cannula is retracted. The obturator must remain fixed in place while the cannula with needle is retracted from the arm. Do not push the obturator.
1. Confirm that the patient does not have allergies to IMPLANON, as well as the antiseptic and anesthetic to be used during insertion.
2. Have the patient lie on her back on the examination table with her non-dominant arm flexed at the elbow and externally rotated so that her wrist is parallel to her ear or her hand is positioned next to her head.
3. Identify the insertion site, which is at the inner side of the non-dominant upper arm about 8–10 cm (3–4 inches) above the medial epicondyle of the humerus. IMPLANON (etonogestrel implant) should be inserted subdermally just under the skin to avoid the large blood vessels and nerves that lie deeper in the subcutaneous tissue of the sulcus between the biceps and triceps muscles.
4. Mark the insertion site with a sterile marker. Make two marks: first, mark the spot where the IMPLANON rod will be inserted, and second, mark a spot a few centimeters proximal to the first mark (see above image). This second mark will later serve as a direction guide during IMPLANON insertion.
5. Clean the insertion site with an antiseptic solution.
6. Anesthetize the insertion area (for example, with anesthetic spray or by injecting 2 cc of 1% lidocaine just under the skin along the planned insertion tunnel).
7. Carefully remove the IMPLANON applicator from its blister. Keep the shield on the needle and look for the IMPLANON rod, seen as a white cylinder inside the needle tip.
8. If you don't see the IMPLANON rod, tap the top of the needle shield against a firm surface to bring the implant into the needle tip.
9. Following visual confirmation, lower the IMPLANON rod back into the needle by tapping it back into the needle tip. Then remove the needle shield, while holding the applicator upright.
10. Note that IMPLANON (etonogestrel implant) can fall out of the needle. Therefore, after you remove the needle shield, keep the applicator in the upright position until the moment of insertion.
11. Keep the IMPLANON needle and rod sterile. If contamination occurs, use a new package of IMPLANON with a new sterile applicator.
12. Apply counter-traction to the skin around the proposed insertion.
13. At a slight angle (not greater than 20º), insert only the tip of the needle with the beveled side up into the insertion site.
14. Lower the applicator to a horizontal position. Lift the skin up with the tip of the needle, but keep the needle in the subdermal connective tissue.
15. While "tenting" (lifting) the skin, gently insert the needle to its full length. Keep the needle parallel to the surface of the skin during insertion.
16. If IMPLANON (etonogestrel implant) is placed too deeply, the removal process can be difficult or impossible. If the needle is not inserted to its full length, the implant may protrude from the insertion site and fall out.
17. Break the seal of the applicator by pressing the obturator support.
18. Turn the obturator 90º in either direction with respect to the needle.
19. While holding the obturator fixed in place on the arm, fully retract the cannula. Note: This procedure is opposite from an injection. Do not push the obturator. By holding the obturator fixed in place on the arm and fully retracting the cannula, IMPLANON will be left in its correct subdermal position. Do not simultaneously retract the obturator and cannula from the patient's arm.
20. Confirm that IMPLANON has been inserted by checking the tip of needle for the absence of IMPLANON. After IMPLANON insertion, the grooved tip of the obturator will be visible inside the needle.
21. Always verify the presence of IMPLANON in the patient's arm immediately after insertion by palpation. By palpating both ends of the implant, you should be able to confirm the presence of the 40 mm rod.
22. Place a small adhesive bandage over the insertion site. Request that the patient palpate IMPLANON.
23. If you cannot feel IMPLANON as a 40 mm long rod, confirm its presence using other methods. Suitable methods to locate IMPLANON are: ultrasound (US) with a high-frequency linear array transducer (10 MHz or greater) or magnetic resonance imaging (MRI). Please note that the IMPLANON rod is not radio-opaque and cannot be seen by X-ray or CT scan. If ultrasound and MRI fail, call 1-877-IMPLANON (1.877.467.5266) for information on the procedure for measuring ENG blood levels. Until you confirm proper IMPLANON insertion, your patient must use a non-hormonal contraceptive method.
24. Apply a pressure bandage with sterile gauze to minimize bruising. The patient may remove the pressure bandage in 24 hours and the small bandage over the insertion site in three to five days.
25. Complete the USER CARD and give it to the patient to keep. Also, complete the Patient Chart Label and affix it to the patient's medical record.