Title
Nexplanon Contraceptive Implant Review
Justification of subject
As a GP working in a deprived inner city practice, the provision of family planning services is high with a high use of the contraceptive implant-Nexplanon.
Nexplanon is a single silastic contraceptive implant impregnated with progesterone, which is licensed for three years. LARCs (long acting reversible contraceptives) are recommended for ladies of all years at risk of pregnancy and should be encouraged in that cohort.
Subjectively, the impression is that women request removal before the three-year renewal date due to vaginal bleeding irregularities relatively often. I wanted to look at the numbers of Nexplanon implants we inserted over a year’s duration and assess how many were removed and for what reason.
Ladies interested in LARC have a counselling appointment, given PIL(Patient Information Leaflet) and a follow-up appointment for insertion. Details of the procedure are documented on an electronic template.
Criterion / criteria
1. The number of Nexplanon contraceptive implants inserted between 01/04/14-31/03/15 at Smith Medical Centre.
2. The number inserted by myself.
3. Patients should have received counselling prior to insertion.
4. Patients should have received a PIL prior to insertion.
5. Manufacturer’s detail of the Nexplanon rod should be entered into the patient’s notes.
6. A diary date for removal should be entered into patients’ notes.
7. Patients should have the Nexplanon implant in situ one year after insertion.
8. Documented problems, complications or side effects.
Standards with justification
3.Although all patients (100%) should receive counselling prior to insertion, a realistic 95% was set
4. Again, this should apply to 100% of ladies but 95% was set.
5. For follow-up and identification purposes, manufacturer’s details should be documented in all patients’ notes and 100% is the gold standard, but 95% was set as being realistic and achievable.
6. For audit purposes and effective follow-up, all patients should have a diary entry of removal date entered. 95% was set as being realistic.
7. Ideally 100% would remain in situ for at least a year, but being realistic 90% was chosen as some ladies may change their mind regarding further pregnancy.
8. 100% would be ideal but as the contraceptive has a hormonal element with potential side effects and involves a minor surgical procedure, 85% was chosen.
Preparation and planning
An electronic search of all patient records was undertaken identifying all ladies who had a Nexplanon contraceptive implant inserted between 01/04/14 and 31/03/15.
First data collection, including dates, comparison with standards set, analysis of data
  1. 46 patients were identified as having a Nexplanon contraceptive implant inserted. 25 of these were for renewals/removal of “old” implants and new ones inserted (62.5%)
  2. 40 were done by myself (87%)
  3. 40/40 received counselling prior to insertion which was documented (100%)
  4. 40/40 received PIL prior to insertion (100%)
  5. 39/40 had manufacturers details entered and documented (97.5%)
  6. 27/40 had a documented diary removal date entered. (67.5%)
  7. 6 patients had their implants removed within a year (15%), so 85% of ladies kept their implants in.
  8. Patient a)Nexplanon removed at 9/12 post insertion due to PV discharge and opted for COC as contraception.
  9. Patient b) Nexplanon removed at 9/12 due to irregular PV bleeding and opted for COC as contraception.
  10. Patient c) Nexplanon removed at 8/12 due to PV bleeding and opted for COC.
  11. Patient d) Nexplanon removed after 4/12 due to boils, abdominal cramps and PV bleeding, opted for COC.
  12. Patient e) Nexplanon removed due to a desire to plan pregnancy.
  13. Patient f) Nexplanon removed at 4/12 due to daily PV bleeding-opted for COC. 5/6-due to side effects (83%), 1/6 for pregnancy plans (17%).
  14. Five patients had their Nexplanon contraceptive implants removed due to unwanted side effects (PV bleeding being by far the commonest complaint). One of these five also complained of discomfort over the insertion site the following day-reviewed and no problems identified. One patient experienced the extrusion of her new rod from the extraction site the following day (it was well documented that this was a technically difficult/challenging removal which took some time). A new rod was inserted at a slightly different location several days later. Therefore, seven reports of side effects in 6 patients were documented (17.5%). 82.5% of patients had no problems.

Proposals for changes and actions taken
The data collected was interesting on several counts. Firstly, we provide a comprehensive service to ladies in our practice and a large number of contraceptive implants are undertaken. The number of re-insertions, either for a second or third time are also high (62.5%).
Very reassuringly all patients had counselling, PIL distribution and documentation of the Nexplanon rod details in their records (100%, standards o f85% exceeded).
Surprising to me was the high number of ladies with no diary entry for removal recorded (67.5%, standard set 95%). There is a template which is used for all Nexplanon insertions and the box is present in that. I have absolutely no explanation as to why I hadn’t put in the review date and there was no consistent explanation in the date collection (i.e. random cases throughout the year and not seasonal etc)
The number of ladies requesting removal due to side effects(most commonly PV bleeding) was not as high as subjectively I had expected, so that was a pleasant surprise (82.5%). I don’t think we will be able to improve on these figures, particularly as it is explicitly laid out that 3/5 women with the Nexplanon contraceptive rod will experience irregular PV bleeding at counselling and 100% of ladies had this along with PIL prior to insertions.
Regarding the diary entry for removal-this requires to be updated. Having undertaken the audit, I am now aware of my past inconsistency in this area and double check before I exit the template to ensure a date is entered.
Second data collection including dates, comparison with first data collection and standards set, analysis of data
The notes were reviewed and where no diary entry for removal was entered this was added.
Second data collection:
6. 40/40 (100%) patients had a diary entry for removal documented in their notes.
Discussion of results
I was surprised at just how many contraceptive implants we inserted over a year, particularly the number of extraction and re-insertions. Each of these double procedures and removal procedures take ½ hour of GP time, which is resource heavy; however, the high number of women continuing with their implants is reassuring.
Side effects were low, and as predicted were mainly irregular PV bleeding. A consistent approach to providing counselling both verbally and in written form was evidenced. Lack of consistency in recording follow-up was identified-which I was previously unaware of; so the audit has highlighted an area which needed improving.
Final conclusions
The Medical Centre seems to be responding to patients requests for LARC in the implant form and has shown a consistent approach in documentation and procedures, with an improvement in recording follow up dates shown in the follow up cycle.