Contraceptive Implant in India and UAE | Complete Patient Guide

• ELIGIBLE CANDIDATES:

• Women seeking highly effective (>99%), long-acting, reversible contraception for up to 3 years

• Women in whom oestrogen-containing contraceptives (combined oral pills, patch, ring, combined injectable) are contraindicated — including those with migraine with aura, personal or family history of VTE, hypertension, liver disease, or cardiovascular risk factors (WHO MEC Category 3/4 for oestrogen)

• Breastfeeding mothers (ENG implant is WHO MEC Category 1 from 6 weeks postpartum; progestogen-only, does not affect milk supply)

• Postpartum women (can be inserted immediately postpartum — within 24 hours of delivery — or at any time if pregnancy is reliably excluded)

• Post-abortion insertion (immediate, same-day insertion recommended by FSRH/WHO to prevent repeat unintended pregnancy)

• Women with medical conditions benefiting from menstrual suppression (endometriosis, dysmenorrhoea, iron-deficiency anaemia secondary to heavy menstrual bleeding)

• Women who desire a 'fit-and-forget' method without daily, weekly, or monthly compliance demands

• Adolescents and young women (no age lower limit; suitable from menarche)

• Women with sickle cell disease (progestogen-only methods are WHO MEC Category 1)

• REQUIRED PRE-PROCEDURE ASSESSMENTS:

• Comprehensive medical and sexual history to assign WHO Medical Eligibility Criteria (MEC) category

• Urine or serum beta-hCG pregnancy test (mandatory on day of insertion to exclude pregnancy)

• Blood pressure measurement

• STI/cervical swab screening if clinically indicated (especially in women with PID history)

• Pelvic examination if clinically warranted

• Ultrasound (not routinely required for standard insertion, but recommended for women with BMI > 30 kg/m² or needle phobia to plan insertion depth and verify placement post-insertion)

• Coagulation screen and liver function tests if hepatic disease is suspected

• ABSOLUTE CONTRAINDICATIONS (WHO MEC Category 4):

• Current or past breast cancer (hormone-sensitive malignancy)

• Severe decompensated cirrhosis

• Hepatocellular adenoma or malignant liver tumour

• Unexplained abnormal vaginal bleeding under investigation (relative — defer until diagnosis confirmed)

• Known or suspected pregnancy

• Hypersensitivity to etonogestrel, EVA matrix components, or barium sulphate (Nexplanon radio-opaque marker)

• RELATIVE CONTRAINDICATIONS / SPECIAL POPULATIONS (WHO MEC Category 2–3):

• Women on enzyme-inducing medications (rifampicin, carbamazepine, phenytoin, St John's Wort) — efficacy may be reduced; concomitant barrier contraception or alternative LARC (IUD) recommended

• Current venous thromboembolism on anticoagulation (Category 2 — benefits generally outweigh risks)

• History of functional ovarian cysts

• Severe depression (monitor; progestogens may affect mood in susceptible individuals)

STANDARD APPLICATOR-GUIDED SUBDERMAL INSERTION (NEXPLANON/IMPLANON NXT PLATFORM):

The current global standard uses the Nexplanon pre-loaded, disposable, modified applicator (MSD/Organon). The device is radio-opaque (contains barium sulphate) for X-ray, ultrasound, CT, and MRI localisation. The single-handed, trocar-based insertion technique deposits the rod at a depth of 3–5 mm below the skin surface in the subcutaneous plane of the medial upper arm. The entire procedure takes 60–90 seconds under local anaesthesia (1–2 mL of 1% lidocaine subcutaneously). No incision or suture is required. A pressure bandage is applied for 24 hours and a small adhesive dressing for 3–5 days.

ULTRASOUND-GUIDED INSERTION (ENHANCED PRECISION PROTOCOL):

For women with a BMI above 30 kg/m², very thin arms with minimal subcutaneous tissue, or significant procedural anxiety, real-time high-frequency (10–15 MHz) linear probe ultrasound guidance is used by experienced gynaecologists to precisely target the subdermal plane, confirm device trajectory, and immediately verify correct placement. This technique is now standard at tertiary gynaecology centres in India and the UAE and virtually eliminates the risk of deep muscular insertion.

IMPLANT REMOVAL — STANDARD TECHNIQUE:

Standard removal is performed under local anaesthesia via a 2–3 mm longitudinal incision over the palpable distal tip of the rod, followed by blunt dissection through the fibrous sheath that develops around the EVA matrix over time, and extraction with mosquito forceps. Procedure time: 5–15 minutes. A new implant can be inserted through the same incision site (simultaneous removal and replacement, or 're-do' procedure).

IMPLANT REMOVAL — DEEP/NON-PALPABLE/IMPALPABLE IMPLANT TECHNIQUE:

Approximately 1–2% of implants become non-palpable, most often due to deep (intramuscular or subfascial) insertion. Management follows a stepwise localisation protocol:

1. High-frequency ultrasound (first-line imaging) — identifies device position and depth relative to the biceps brachii muscle and neurovascular bundle.

2. MRI of the upper arm (second-line if ultrasound inconclusive) — superior soft tissue contrast to delineate implant in relation to vessels and nerves.

3. Fluoroscopy/X-ray — useful as Nexplanon is radio-opaque; confirms presence and gross location.

4. Surgical removal under ultrasound-guided real-time visualisation — performed in a minor operating theatre setting with a surgeon experienced in deep implant retrieval. In rare cases of intravascular migration (reported in < 0.03% of cases), cardiothoracic or vascular surgical involvement may be required.

RE-INSERTION TIMING OPTIONS:

• Immediate re-insertion (same visit, through same incision)

• Delayed re-insertion (at next menstrual period or after pregnancy exclusion)

EMERGING TECHNOLOGIES:

Some centres in India and the UAE are piloting near-infrared (NIR) detection devices (e.g., SENSITEC detector systems) to aid non-palpable implant localisation in outpatient settings without radiation exposure, representing the next frontier in implant management.

STEP 1 — PRE-TRAVEL VIRTUAL CONSULTATION (1–2 weeks before travel):

GAF Healthcare coordinates a teleconsultation with the receiving gynaecologist. The patient submits medical history, current medications, recent blood tests, and BMI. The clinician assigns WHO MEC category, confirms eligibility, and schedules the insertion appointment. The optimal timing within the menstrual cycle is planned (Days 1–5 preferred for immediate contraceptive cover; any day if pregnancy is excluded, with 7-day barrier contraception backup).

STEP 2 — ARRIVAL AND DAY-OF-PROCEDURE ASSESSMENT (Day 1 in destination country):

The patient attends the clinic or outpatient gynaecology department. A urine pregnancy test is performed. Vital signs and blood pressure are recorded. The procedure, risks, alternatives, and expected bleeding pattern changes are discussed using standardised counselling (FSRH/WHO framework). Written informed consent is obtained.

STEP 3 — INSERTION PROCEDURE (Day 1, typically a 20–30 minute appointment):

The patient lies supine with the non-dominant arm abducted and externally rotated (hand behind the head). The inner upper arm is cleaned with antiseptic. Local anaesthesia (1–2 mL lidocaine 1%) is infiltrated subdermally. The Nexplanon applicator is positioned at 0° (parallel to the long axis of the arm). The needle is advanced to its full length in the subcutaneous plane, the obturator is retracted, and the rod is deployed. Tactile confirmation is performed immediately — both clinician and patient should be able to palpate the rod. In high-BMI or complex cases, ultrasound confirmation is performed at the table. A pressure dressing and steri-strips are applied. The implant lot number and site are documented in the patient's health record and on a patient-held implant card.

STEP 4 — IMMEDIATE POST-PROCEDURE OBSERVATION (30–60 minutes):

The patient rests briefly in the recovery area. Bruising, arm tenderness, and normal expected side effects are reviewed. Analgesic advice (paracetamol or ibuprofen as required) is provided. The patient is given written aftercare instructions and the 24-hour GAF Healthcare patient support contact.

STEP 5 — RECOVERY AND RETURN TO DAILY ACTIVITIES (Days 1–7):

• Day 1–2: Mild bruising and tenderness at insertion site expected. Keep site dry for 24 hours; avoid heavy lifting with the affected arm for 48 hours. Pressure bandage removed after 24 hours; adhesive dressing retained for 3–5 days.

• Day 2–3: Most patients feel completely normal. The implant is not visible but should be palpable as a small firm rod.

• Day 7: Full return to all physical activities, including exercise and swimming.

STEP 6 — FIT-TO-FLY CLEARANCE AND DEPARTURE (Day 1–2 post-insertion):

There is no physiological contraindication to air travel after subdermal implant insertion. Most international patients fly home on the same day or the following day. GAF Healthcare provides a signed medical summary letter detailing the device type, lot number, insertion date, and removal date (3 years hence) for the patient to carry while travelling — essential for security screening transparency and future healthcare providers.

STEP 7 — POST-RETURN FOLLOW-UP (Weeks 1–4 and Ongoing):

• 1-week teleconsultation with the GAF Healthcare-coordinated gynaecologist to review any site concerns or unexpected bleeding patterns.

• Ongoing virtual access to the treating clinician for 90 days post-procedure as part of GAF Healthcare's aftercare protocol.

• 3-year implant lifespan: Patient is counselled on removal and replacement timing and advised to register the implant with their home-country gynaecologist.