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Nichamon Parkpinyo, M.D., Nalinee Panichyawat, M.D., KorakotSirimai, M.D.

Department of Obstetrics & Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, ailand.

Early Removal of the Etonogestrel Contraceptive

Implant and Associated Factors Among Users at the

Urban Family Planning Clinic in Siriraj Hospital,

Bangkok, Thailand

ABSTRACT

Objective: To study the rate and reasons for the early removal of etonogestrel contraceptive implants and associated

factors at the family planning clinic in Siriraj Hospital.

Materials and Methods: is retrospective cohort study was conducted between May 2015 and December 2019 and

contained 1,030 women who received the etonogestrel contraceptive implant. e medical records of demographic

characteristics and clinical factors i.e., implant insertion date, implant removal date, reason for implant removal,

contraceptive use before implant insertion and aer implant removal, documented bleeding pattern and acceptability,

were identied.

Results: e mean age of participants was 28.6 ± 6.9 years. About 21% of women (218/1030) prematurely discontinued

their etonogestrel implant. A desire to become pregnant was the most common reason for early removal of the

etonogestrel implant (32%). Meanwhile, the most common side-eect contributing to early removal was unscheduled

bleeding. e associated variables of early etonogestrel implant removal were low BMI (p-value = 0.021) and

unacceptability of bleeding pattern at one year (p-value < 0.001) and two years (p-value < 0.001) aer insertion.

Conclusion: Early etonogestrel implant discontinuation rate was remarkable and the main reasons for it include

a desire to become pregnant and bleeding side eects. Moreover, a lower BMI and unacceptability of bleeding

problems also increased the likelihood of early removal of this contraceptive method.

Keywords: Etonogestrel implant; contraceptive method; one rod contraceptive implant; implant removal; implant

discontinuation (Siriraj Med J 2021; 73: 399-405)

Corresponding author: Korakot Sirimai

E-mail: ksirimai@hotmail.com

Received 18 January 2021 Revised 24 February 2021 Accepted 26 February 2021

ORCID ID: http://orcid.org/0000-0002-7475-7757

http://dx.doi.org/10.33192/Smj.2021.53

INTRODUCTION

Family planning plays an essential role in women’s

health by reducing the mortality rate of unsafe abortions

and undesired pregnancies. Today, various methods of

modern contraception focus on techniques that have

proven to be eective and are widely used.

For example,

long-acting reversible contraceptives (LARCs) are birth

control methods that provide eective contraception

long-term without requiring user action. Contraceptive

methods that fall under LARC include intrauterine devices

(IUDs) and subdermal contraceptive implants.

e

etonogestrel contraceptive implant (Implanon NXT®)

is a single-rod progestin-only device containing 68 mg

of etonogestrel preloaded in a 4-cm so plastic stick.

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Parkpinyo et al.

provides protection for three years and its mechanism

is based on ovulation inhibition and an increase in the

viscosity of the cervical mucus.

Although the three-year etonogestrel contraceptive

implant is eective and popular among users, common

side eects include unscheduled bleeding, weight gain,

acne, headache and loss of libido. ese side eects are

all possible reasons for the early discontinuation of this

contraceptive method.

In developing countries, removal

of the etonogestrel implant in the rst year (13%-28% of

all cases depending on the area of study) is common even

though these women are still in need of contraception.

6-9

Various studies have noted that women may insist on the

early removal of the etonogestrel implant for a variety

of reasons. For example, some studies have noted that

unscheduled bleeding and other side eects are common

reasons for early removal.

10-12

In fact, unscheduled bleeding

was the most frequently cited reason for early removal of

implants in a large multicenter trial in seven countries.

To solve this problem, counseling women on expected

bleeding patterns might improve the longevity of implantable

progesterone contraceptives. Furthermore, a low body

mass index was also associated with early discontinuation

of implants in a prior study,

9,14

however, these studies failed

to identify sociodemographic predictors or associated

factors of early discontinuation.

14-16

Moreover, most

studies only had a follow-up period of one year.

6-9

with

only a few studies maintaining a three-year follow-up

period in a small population group.

Although there are several studies about long-acting

reversible contraceptives in ailand

18-20

, published data

on the discontinuation rate of etonogestrel implants

and associated factors are insucient. Moreover, Siriraj

Hospital provides family planning services and reproductive

healthcare for many women. is study aimed to investigate

the rate and reasons for early removal of etonogestrel

implants and associated factors in large sample size and

long-term period. Accordingly, this study will be expedient

to determine the current practice of etonogestrel implant

discontinuation and ndings from this study will also

be helpful in improving the reproductive healthcare

system.

MATERIALS AND METHODS

This retrospective cohort study was conducted

aer the Ethics Committee of SIRB (Si 406/2020(IRB2))

approved the study. is study enclosed women who

received an etonogestrel contraceptive implant removal at

the family planning clinic, Siriraj Hospital between May

2015 and December 2019. In Siriraj Hospital, it is common

platform at our institution to provide contraceptive

counselling and appropriate instruction regarding the

chosen method. e etonogestrel implant available in

ailand during the study period was Implanon NXT®,

a single-rod progestin-only device containing 68 mg of

etonogestrel preloaded in a disposable applicator and

approved by the US FDA for a duration of three years

of use.

First, medical records of women who had an

etonogestrel implant inserted during the study period

were identied. e investigators did not exclude women

based on the indication of implant use. Regarding

preciseness, two investigators reviewed each medical

chart and discrepancies noted were normalized through

discussion amongst all investigators. e authors recorded

the following parameters from each medical record:

sociodemographic characteristics, reproductive and

obstetric history, utilization past contraceptive history,

implant insertion & removal date, reason for requesting

removal, documented bleeding pattern and acceptability.

Bleeding patterns, which were recorded at the one year,

two year, and three year visit was assorted as either

regular bleeding or unscheduled bleeding. Documented

bleeding complaints were ascertained by reviewing the

charts and classied as acceptable or unacceptable.

e primary outcome was an early removal rate of

the etonogestrel implant. “Early removal” was dened

as removal of etonogestrel implant within 36 months of

insertion. Furthermore, a medical record documented

implant removal as early discontinuation either at our

institution or any other outside clinic within 36 months

aer implant insertion. Last but not least, secondary

outcomes and associated factors for early removal were

also documented.

e data was analyzed using the SPSS soware

package (SPSS version 18.0; IBM). e demographic data

and descriptive statistics were presented as percentage

and Mean ± SD while the association between variables

and implant discontinuation status was identied by a

Chi-square test and Fischer’s exact test. A p-value <0.05

was considered statistically signicant.

RESULTS

A total of 1,030 women with records of etonogestrel

implant insertion during the study period were assembled.

e mean age of the participants was 28.6 ± 6.9 years

and the majority of women in this study were married

and/or parous women. e mean BMI was 23.2 ± 4.7 kg/

. and the most recently used method of contraceptives

was oral contraceptive pills (35.3%). Also, at least 15%

of the women had never used any contraceptive method

(Table 1).

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TABLE 1. Sociodemographic characteristics of participants.

About 21% of women (218/1,030) recorded early

etonogestrel implant discontinuation (within three years

following implant insertion (Table 2)). Among them

who had early implant removal, the most commonly

cited reason was an intention of becoming pregnant

(32.1%), bleeding disturbances (22.5%) and weight gain

(12.8%) (Table 3). e “others” parameter in Table 3

includes loss of libido, mood changes, desire for male

contraception and a desire for tubal sterilization. For

most women in early removal group, the contraceptive

method post etonogestrel implant removal was oral

contraceptive pills. Moreover, 44% of the women who

had used etonogestrel implants until the end desired to

have it reinserted aer removal.

e authors conducted contemplation to explore

the factors associated with etonogestrel implant removal

before three years. e associated variables of early

etonogestrel implant removal were BMI (p-value =

0.021) and acceptability of bleeding patterns at one year

(p-value < 0.001) and two years (p-value < 0.001) aer

insertion (Table 4). Gravidity, parity and marital status

had no relation or impact on the decision to have the

etonogestrel implant removed. As mentioned previously

about BMI, the authors noticed that a low BMI was

associated with early removal of etonogestrel implants

(OR = 1.71; p-value < 0.05).

Characteristics n (%) (N=1030)

Gravidity

Nulligravid 113 (11)

Gravidity = 1 558 (54.2)

 Gravidity≥2 359(34.8)

Parity

Nulliparous 155 (15)

Parity = 1 617 (60)

 Parity≥2 258(25)

BMI

< 25 kg/m

693 (67.3)

 ≥25kg/m

337 (32.7)

Marital status

Married 933 (90.6)

Single 69 (6.7)

Divorced 28 (2.7)

Recent contraceptive method

Hormonal method

Oral contraceptive pills 364 (35.3)

DMPA 168(16.3)

3-year Implant 70 (6.8)

5-year Implant 42 (4.1)

Emergency contraceptive pills 28 (2.7)

Progestin only pills 6 (0.6)

Non-hormonal method

Male condom 141 (13.7)

Cu-IUD 24 (2.3)

Withdrawal 17 (1.6)

Others 16 (1.6)

Never use 154 (15.0)

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DISCUSSION

Our study shows important data and useful insights

about the patterns of etonogestrel implant use and reasons

for early removal among users in ailand. e study

also provides the trends in usage as information from

all users requesting removal was collected and not just

from those who requested early removal of the device.

e population in this study was on average around

twenty-eight years of age and had a normal BMI which

is representative of the ai population.

In our study, 21% of etonogestrel implant users had

their implant removed within three years of insertion.

e result was lower than studies in other developing

countries.

21-22

is discrepancy might be due to sample

size, timing of the study, socio-cultural dierences, and

the government’s role in minimizing early removal of

etonogestrel implant. e desire to become pregnant was

the most common reason for early removal of implants

in this study (32%), which infers that counseling services

given to patients about the contraceptive method and its

duration during inception is very essential. Moreover,

side-eects were cited as the most common reasons for

early removals, especially unscheduled bleeding. is has

also been found in other studies.

10-13

In comparison to

ai population-based study, Assavapokee N et al. found

that the discontinuation rate of etonogestrel implant

within 3 years was 16.9% and unscheduled bleeding was

the main reason for early implant removal.

Of all the demographic characteristics and clinical

factors that we studied; one-year and two-year acceptability

of bleeding problems and BMI were the most cited

factors associated with early removal of the etonogestrel

TABLE 2. Duration of etonogestrel implant use at the time of removal.

TABLE 3. Reasons for early removal of etonogestrel implant.

Duration n (%) (N=1030)

Early removal 218 (21.2)

< 6 months 17 (1.7)

6 months to 1 year 54 (5.2)

> 1 year to < 2 years 69 (6.7)

 ≥2yearsto<3years 78(7.6)

Noearlyremoval(≥3years) 812(78.8)

Reason n (%) (N=218)

Wish to become pregnant 70 (32.1)

Bleeding disturbance 49 (22.5)

Weight gain 28 (12.8)

Acne 23 (10.6)

Separation 23 (10.6)

Dizziness 16 (7.3)

Headache 14 (6.4)

Insertion site problem 5 (2.3)

Others 26 (11.9)

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TABLE 4. Bivariate comparison of characteristics by etonogestrel implant discontinuation status.

Characteristics Early removal No early removal p-value

(N = 218) (N = 812)

Gravidity 0.255

Nulligravid 30 (13.8) 83 (10.2)

Gravidity = 1 110 (50.4) 448 (55.2)

 Gravidity≥2 78(35.8) 281(34.6)

Parity 0.669

Nulliparous 37 (17.0) 118 (14.5)

Parity = 1 128 (58.7) 489 (60.2)

 Parity≥2 53(24.3) 205(25.3)

BMI 0.021

< 18.5 kg/m

41 (18.8) 97 (12.0)

18.5-24.9 kg/m

105 (48.2) 450 (55.4)

 ≥25kg/m

72 (33.0) 265 (32.6)

Marital status 0.065

Married 189 (86.7) 744 (91.6)

Single 22 (10.1) 47 (5.8)

Divorced 7 (3.2) 21 (2.6)

Bleeding problem

1-year after insertion

Bleeding pattern 0.539

Regular bleeding 18 (12.1) 84 (10.3)

Unscheduled bleeding 131 (87.9) 728 (89.7)

Acceptability <0.001

Acceptable 135 (90.6) 797 (98.2)

Not acceptable 14 (9.4) 15 (1.8)

2-year after insertion

Bleeding pattern 0.196

Regular bleeding 6 (10.3) 109 (16.9)

Unscheduled bleeding 52 (89.7) 536 (83.1)

Acceptability <0.001

Acceptable 53 (91.4) 635 (98.4)

Not acceptable 5 (8.6) 10 (1.6)

3-year after insertion

Bleeding pattern 1.000

Regular bleeding 0 (0) 185 (23.9)

Unscheduled bleeding 0 (0) 590 (76.1)

Acceptability 1.000

Acceptable 0 (0) 743 (95.9)

Not acceptable 0 (0) 32 (4.1)

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implant. First-year unscheduled bleeding was found

in 89% of women in this study, which emphasizes the

importance of counseling patients about expected side-

eects and appropriate management before oering

the contraceptive choice. Acceptance of potential side-

eects before choosing the contraceptive method may

decrease the early discontinuation rate. Only a few women

reported acne, weight increase, dizziness, and headache

as reasons for early removal of the etonogestrel implant.

e side-eects found in our study are corresponding

to the potential side-eects of the etonogestrel implant.

In this study, the author observed that Low BMI was

associated with early removal of etonogestrel implants.

ere are studies support that the lower basal BMI may

account for the higher percentage of irregular bleeding.

Moreover, obese women were 2.6 times less likely to have

implant removal for bleeding as compared with normal

weight women. It could be hypothesized that the eect

of higher endogenous estrogen levels in women with

higher BMI stabilizes the endometrium.

Moreover, we also noticed in this study that almost

half of the women who had used etonogestrel implants

until the end desired to have it reinserted aer removal,

demonstrating acceptability and satisfaction of this method.

As we know that etonogestrel implants oer the benets

of long action of use and reversibility. In this study, we

gured out that the most common reasons for intending

to use an etonogestrel implant was the desire for a long-

acting contraceptive method that did not require frequent

follow-ups.

CONCLUSION

In conclusion, the study revealed that early etonogestrel

implant discontinuation rate is signicant and that the

main reasons for early removal was a wish to become

pregnant and/or bleeding side eects. e study also

suggests that a lower BMI and unacceptability of bleeding

problems increases the likelihood of early removal of

this contraceptive method.

ACKNOWLEDGMENTS

e author would like to express their gratitude to

all the sta of the family planning clinic, Siriraj Hospital

for their assistance in data collection and Dr. Saowaluck

Hunnanggul from the Clinical Epidemiology Unit for

assistance in statistical analysis.

Conict of interests: e authors declare that they have

no conict of interests.

Ethical issues: is study was conducted aer obtaining

necessary permissions from the Ethics Committee of SIRB

(Siriraj Institutional Review Board: 406/2563(IRB2)).

All ethics were respected in this study.

Financial support: e authors received no external

funding for this research.

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