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��ࡱ�>��	Y[����X�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�	��Cbjbj����	4bΐΐ;����������������������dM�Y'0iiiiiXXX�&�&�&�&�&�&�&�(�++H�&�XXXXX�&��ii�'nnnX��i�i�&nX�&nn��i����p�gI���^��&)'0Y'�,s+L"s+�s+���XXnXXXXX�&�&nXXXY'XXXX��������������������������������������������������������������������s+XXXXXXXXX�	�:	MISSING IMPLANON, REPORT OF TWO CASES 
Mbamara Sunday Uche*, **Mbah Ikenna 
*Department of Obstetrics and Gynaecology, Abuja Clinics LTD, Ministers� Hill, Maitama, Abuja, FCT
** Department of Radiology, Abuja Clinics LTD, Ministers� Hill, Maitama, Abuja, FCT. 









Corresponding Author 
Mbamara SU
Box 354, Amaraku P.O
Imo � state 
Nigeria
kensunny30@yahoo.co.uk






MISSING IMPLANON, REPORT OF TWO CASES 
Abstract
Contraceptive practice is a major public health issue in Nigeria and other sub-Saharan African countries with high fertility rate. Among the available methods of contraception is Implanon contraceptive implant which provides a highly effective, convenient, nonuser-dependent, reversible contraceptive method. However, implanon is not without of complications. These complications could be as a result of the inherent effect of the active drug or the process of insertion and removal. Here we report of cases of missing Implanon as a result sitting the implanon in an unusual location and prolonged use for over 9 years before seeking for removal. 
Key words; Implanon, missing, non palpable, contraception

Introduction
Contraceptive technology has been in existence for over a century and millions of women have used this technology to delay, space or limit their number of childbirth. Contraceptive Implants are among the newer forms of birth control.  The Etonogestrel releasing implants have been shown to be safe and effective contraceptive method with a Pearl index 0. 381 They are easy to use, of long duration and reversible. However certain risks relating to the procedure of insertion and removal has been noted. Here in this report are two cases of missing implanon, one as a result insertion of implanon on an unusual site and the other as a result of prolonged use for 9 years.
Case 1
A 37 year old Para4 business woman presented at the gynaecology clinic of Abuja clinics LTD on the 13th of March 2013 with complaints of irregular menses of 3months duration and the feeling that she was pregnant.  She has worn implanon contraceptive implant for about 9years which was inserted elsewhere in a clinic abroad when her husband was on a foreign mission. She was advised to remove or replace the Implanon after 3 years but she defaulted. She claimed she returned to Nigeria and was waiting for an opportunity to travel back abroad to remove it. She believed she ought to have it removed where it was inserted. She also claimed she initially forgot about the implant but on remembering she later visit three hospitals for removal of the Implanon but none could palpate or locate it. She desired/tried to achieve pregnancy six years post-insertion due to pressure from her husband but to no avail. She had some periods of irregular menses within the first three years of the Implanon insertion. She did not suffer any other complications.  She claimed the menses later normalized before the current episode that made her to present. She requested for another contraceptive method after it was confirmed that she was not pregnant because she believed she is too old to start nursing a baby. Her contraceptive options were discussed with her and she was placed on Drospirenone + Ethinylestradiol (YAZ). Her first confinement was in 1998 while the last confinement was in April 2003. All her pregnancies were by spontaneous vertex delivery. There was nothing significant in her past medical and surgical history. There was no history of allergy. There was no abnormal finding on examination. Her blood pressure was 120/70mmHg, pulse � 72bpm and weight was 70kg. Pelvis examination was also normal. Ultrasonography did not reveal any foreign structure or implant. She considered MRI to be too expensive for localization of the implanon implant. 

Case 2 
A 29 year old Para2 student with one living child attended the gynaecology clinic of Abuja clinics Limited Maitama on the 25th of November 2013 requesting for the removal of her contraceptive implant - implanon.  She wants the Implanon removed because of excessive weight gain and also a desire to become pregnant. She had the impalnon inserted elsewhere on the 30th of September 2012 about six weeks after her last delivery which was through caesarean section and fourteen months prior to presentation. She had about 20kg increase in weight from a pre-insertion weight of 90kg to 110kg despite the measures she took to limit the weight gain like dieting and exercise.  She had menstrual changes - spotting, irregular menses, heavy and prolonged menstrual flow (lasted about 7-10 days) with the insertion of the implanon She was very disturbed by her weight gain and menstrual changes which she fears may affect her future fertility.    No other complication was recorded.  She had visited 3 other hospitals requesting for the removal of the implanon but none could palpate or locate it.  There was no other relevant medical history. General examination revealed an obese woman with a BMI of 40.4kg/m2, her blood pressure was 110/70mmHg, pulse 72bpm. Initially the implanon could not be palpated on the left arm. There was no abnormal finding on examination of the systems.   Ultrasonography of the left arm could not detect the contraceptive implant. The implanon was later located on the medial aspect of the left arm about 2 - 2.5cm (1-1.5 inches) from the medial epicondyl of the left elbow after several repeated examinations. The implanon was then removed under local anaesthesia using a 2mm sized incision as an outpatient procedure.

Discussion 
Implanon is a progesterone only, long acting, and reversible method of contraception. It is non-biodegradable, Etenogestrel containing, single, sterile, 4cm x 2mm rod implant for subdermal insertion. Implanon is one of the 3 implants available in our market.  Nexplanon Implanon NXT a newer single rod progesterone only contraceptive implant is not yet available in our market. Like Implanon it contains 68mg Etonogesterel but has in addition 3% Barium Sulphate which makes it easy to be detected by conventional X-ray imaging2. Implanon is recommended to be inserted in the medial aspect of the upper non-dominant   arm 8 � 10cm (3-4inches) above the medial epicondyl of the humerus /elbow from a preloaded inserter3. It should be easily palpable after insertion if properly inserted.  It offers effective contraception for 3 years. It has the advantage that its efficacy does not depend on repeated administration or user dependent. 
The complications of impalnon are similar to other available implants. These complications include changes in menstrual pattern, excessive weight gain, acne, mood swing, and ectopic pregnancy. It has also been associated with increased incidence of myocardial infarction, ovarian cyst and pulmonary embolism. Changes in menstrual pattern have been noted as the single most common reason for the discontinuation of the implanon.  
 The complication reported here is non- palpable or missing impalanon due to siting of the implanon in an unusual location.  Missing implanon as a complication of implanon contraceptive implant has been corroborated by different reports4.  In this report the rods were deemed missing because they were not or easily palpated after repeated examinations by different physicians at different hospitals. We suspect that case 1 may be as a result of non insertion or migration due to prolonged use since implanon is non biodegradable. Case 2 is caused by abnormal siting of the implanon. All the initial examinations including ours must have been concentrated around the usual recommended site of insertion (ie the middle aspect of the left arm 8 - 10cm from the medial epicondyle of the humerus) hence the inability to palpate or locate the implanon.  Eventually the location of the Implanon was accomplished by palpating around a 1-2cm scar noted about 1.5-2.5cm from the medial epicondyle of the humerus of her left arm. This location is unusual for the insertion of Implanon and our literature search could not locate any report where the Implanon contraceptive implant is located in a similar site. 
It is our belief that the physician that inserted the Implanon may have chosen this site because of the size of her arm circumference or obese nature of the woman but failed to inform her. This case suggests that the entire arms should be carefully examined repeatedly and any scar on the arm should be carefully explored when searching for any missing/non palpable contraceptive implant. It also brings to fore the need to inform the patients either verbally or in writing of any modifications made during her treatment. 
Several factors like non-insertion, inserting deep into the muscle and migration4, have been associated with missing or non palpable implant. Other factors associated with non-palpable or   missing implanon implant include scarring, attempted removal or significant weight gain5, 6. 
The diagnosis of missing implanon is usually made clinically when there is a failure to palpate the implant.  Ultrasound has been suggested to be the investigation of choice7, 8 in detecting missing implanon but Ultrasound imaging of these patients� arms failed to detect the implants. Similarly the inability of the Ultrasonography to sometimes detect or localize the implanon contraceptive implants    has also been documented by other reports9, 10.   Several researches have documented the use of real time high frequency transducer (12.5 � MHz) ultrasound scan and magnetic resonance imaging (MRI) for the location of and as a guild for the removal of non palpable and intramuscularly placed implants11.    The use of high frequency 12.5MHz linear probe and expertise in the location of contraceptive implants on the part of the radiologist are important prerequisites for the location of Implanon using ultrasound scan7.  Failure to detect implant by ultrasound scan could be as a result of non-insertion, too much pressure on the probe, ultrasound probe with low frequency, and limited experience of the sonogragher on impalnon scan.  MRI is regarded as a second line imaging modality but its use in our environment is limited by availability, affordability and accessibility. 
The management options for missing implanon include surgical removal, surgical exploration and removal, surgical removal under ultrasound or Magnetic Resonance Imaging (MRI) guidance.  Most removal failures or complications arise if the initial insertion is too deep12  and if it is not properly located or palpated throughout its length. 
The implanon was left in our case 1 patient since it could not be located and she could not afford MRI for further evaluation. On the alternative she (case1) was commenced on another form of contraception in other to meet her contraceptive need. It has been noted that the contraceptive efficiency of the implant cannot be guarantee after three years. Women who had their implanon left in-situ may be at the risk of prolonged contraception and prolonged adverse affects especially allergy. 
However Mrs  --- the case 2 patient had surgical removal of the implanon as an outpatient immediately it was localized.  It was a small, faint, 2mm scar about 1.5 � 2.5cm from the medial epicondyl of the humerus of the left arm that gave out the site of the implanon insertion. This scar can easily be over looked / dismissed with other minor scars on her left arm.  The marked weight gain could have contributed in concealing the implanon markings.     
No attempts were made on both patients to remove or explore for the Implanons without localization. Attempting to remove an implant which is not palpable can cause scarring, nerve and blood vessel damage. This is an important precautionary step to avoid failed and repeated procedures which have been documented as one of the complication of Implanon removal14.  Other documented complications of removal of implanon include deep insertions, fibrous adhesion, difficulty in finding the impant, broken implants and migration.  
The implanon was worn about 6 years longer than the recommended duration in case 1 due to the erroneous belief that it can only be removed by the clinic that inserted it. This calls for an improvement on the content and quality of counseling given to the patients before the initiation of contraception.
Careful and adherence to the prescribed technique and confirmatory palpation of the implant by both the patient and the physician will reduce the incidence/occurrence of missing implanon. Any changes on the usual site of insertion should be communicated to the patients to reduce insertion and removal difficulties.
 It is our thinking that a change from impanon to Nexplanon in our environment will make it easier to detect missing implanon in our depressed economy, reduce anxiety of women over missing implanon and possibility increase contraceptive acceptability. Although this will require training and retraining of staff involved in the insertion of implants but in the long run will allay and increase acceptability. Meanwhile we posit that Implanon should be inserted by only trained providers and training and retaining of radiologist on ultrasound detection of contraceptive implants should be encouraged and supported. 


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Mansour D, David Richardson. Location and removal of non palpable implanon implants with the aid of ultrasound guild. sJ Fam Plann Rep Health Care 2006; 32(3): 153 - 156. 
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