Non-Palpable Contraceptive Implant Evaluation and Removal: A Protocol That Can Be Adopted for Practice in Low-Middle Income Countries.

Currently, there are four implants that a family planning provider might encounter for removal: Jadelle (two radiopaque, flexible cylindrical implants, 43 mm × 2.5 mm, consisting of dimethylsiloxane/methylvinylsiloxane copolymer core enclosed in thin-walled silicone casing. Each implant contains 75 mg of levonorgestrel, FDA approved for 5 years of use); Levoplant (which is very similar to Jadelle but is only FDA approved for 4 years); Nexplanon (a single, radiopaque rod (40 mm × 2 mm) made of ethylene vinyl acetate copolymer. Each implant contains 68 mg etonogestrel. FDA approved for 3 years of use); and Implanon (a single, non-radiopaque rod (40 mm × 2 mm) made of ethylene vinyl acetate copolymer. Each implant contains 68 mg etonogestrel. FDA approved for 3 years of use). Most implants can be easily palpated after insertion as well as at the time of removal, but in a small number of cases, the implant may not be palpated due to a variety of factors: a clinician inserted the implant deeper than the subcutaneous layer or in a place other than is recommended; the implant was not inserted at all; a woman has gained significant weightand there is increased subcutaneous fat overlying the implant; or the implant has migrated away from the insertion site. Of importance is that if the implant cannot be palpated, no attempt should be made to remove it until it can be localized. Given the rising use of long-acting reversible contraceptives (LARCs), a standardized approach to difficult implant removals is essential, especially in low-middle income countries (LMICs). In this protocol, we demonstrate a step-by-step approach for identification and removal of non-palpable implants that can be adopted for practice across LMICs. This protocol may also serve as a foundation for broader clinical guidelines and training programs.