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Review Article

Contraceptive implants: A review and current perspective in

southwest Nigeria
Olatokunbo Olayiwola Kolawole, Oluwaseun Oludotun Sowemimo, Opeyemi Olawale Ojo,
Olusola Benjamin Fasubaa
Department of Obstetrics, Gynaecology and Perinatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile‑Ife,
Osun State, Nigeria

ABSTRACT
Contraceptive implants are highly cost‑effective forms of long‑acting reversible contraception. They are the most effective
reversible contraceptives and are more effective than sterilization. Pregnancies are rare in women using this method of
contraception, and those that do occur must be fully investigated. There are very few contraindications to use of implants, and
they have an excellent safety profile with very high acceptability and continuation rate. Other benefits include noninterference
with intercourse, immediate onset of action, and return to fertility after removal, improvements in dysmenorrhea, ovulatory
pain, and endometriosis. Despite the numerous advantages, the uptake of contraceptive implants is still very low in the
southwestern part of Nigeria. This may be due to lack of public awareness about their numerous benefits. Efforts should be
made to increase awareness via campaigns and health education. Also, there should be easy accessibility to the contraceptive
implants and continuous training of family planning providers on the insertion and removal techniques.

Key words: Contraceptive; etonogestrel; levonorgestrel; long‑acting reversible contraception; progestin‑only; subdermal
implant.

Introduction More than 220 million women in developing countries

currently have an unmet need for modern contraception,
Contraception is the act of preventing pregnancy by
mainly in sub‑Saharan Africa,[2] whereas majority of women
interrupting the chains of events that lead to conception.
using contraception rely on the traditional and less effective
It is very paramount in reducing the risk of unintended
forms of contraception. Wider uptake of long‑acting
pregnancies and its attendant complications especially
reversible contraceptive (LARC) methods is expected to
because of the strict abortion laws in Nigeria. It has been
reduce the high rate of unintended pregnancy. LARCs have
estimated that of the 210 million pregnancies that occur
been defined in the UK National Institute for Health and Care
annually worldwide, about 80 million (38%) are unplanned,
Excellence guideline as contraceptive methods that require
and 46 million (22%) end in abortion. [1] Unintended
administration less than once per cycle or month.[3] Included
unprotected intercourse is the primary cause of unwanted
in the category of LARCs are progestin‑only contraceptive
pregnancies, and many women with unwanted pregnancies
decide to end them by abortion, which is mostly unsafe. The Address for correspondence: Dr. Olatokunbo Olayiwola Kolawole,
consequences of these clandestine abortions are grave and Department of Obstetrics, Gynaecology and Perinatology,
Obafemi Awolowo University Teaching Hospitals Complex, Ile‑Ife,
can be life‑threatening, often leading to maternal morbidity
Osun State, Nigeria.
and mortality. E‑mail: [email protected]

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DOI:
How to cite this article: Kolawole OO, Sowemimo OO, Ojo OO,
10.4103/TJOG.TJOG_6_18 Fasubaa OB. Contraceptive implants: A review and current perspective in
southwest Nigeria. Trop J Obstet Gynaecol 2018;35:108-12.

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Kolawole, et al.: Review of contraceptive implants in southwest Nigeria

implants and others. Contraceptive implants are progesterone Norplant: The Norplant contraceptive implant consists of
only contraception that are inserted subdermally. They are six silastic capsules, each contains 36 mg of LNG, and when
highly effective, suitable for nearly all women and it is gaining inserted under the skin, provides a continuous release
more popularity. It is used to space, or limit pregnancies. of LNG at the rate of 30 mcg/day. It provides protection
Contraceptive implants offer immense potential to meet the against pregnancy for 5 years. The associated pregnancy
need for family planning. They are readily reversible with a rate varies between 0.2 and 1.3 per 100 women‑years. Its
return to fertility within days of removal. Moreover, these use and acceptability was hampered by the six rods with
contraceptive devices can be safely placed in the immediate associated difficult insertion and removal,[10] which led to its
postpartum period, ensuring good contraceptive coverage. abandonment in many countries of the world.
Irregular bleeding is their common side effect.
Norplant‑2 (Jadelle/Sinoplant‑11): This method comprises
Historical Background two‑rod silastic implants each measuring 43 mm long and 2.5 mm
in diameter. Each rod contains 75 mg of LNG with a calculated
Norplant[4] was the earliest implant and it was first produced
mean daily in vivo release rate of about 100 μg/day at the 1st month,
in Finland in 1983 with a 5‑year lifespan. It contained six rods,
followed by a gradual decline to about 40 μg/day at 12 months,
each containing levonorgestrel (LNG). Continuing research
and to about 30 μg/day at 24 months, with stabilization thereafter
centered on reducing the number of units to facilitate
at about 30 μg/day. Jadelle was initially licensed for 3 years; this
easier insertion and removal led to its successor, Norplant‑2
has been extended to 5 years in most countries. Sino‑implant
or Jadelle® two‑rod implant, which was approved in the
(ll) is licensed for 4 years. Jadelle has been extensively evaluated,
United States in 1996 but its production, was discontinued
together with its predecessor Norplant, and had been found to
globally in 2008. Implanon[5] was launched in 1999 as a
be safe and highly effective.[11,12]
single rod of etonorgestrel, with contraceptive efficacy of
3 years. Its successor, Implanon NXT® (Nexplanon®),[5] with
Implanon: Implanon is a single rod contraceptive implant
a redesigned applicator to ease its insertion, was introduced
and it provides contraceptive protection for 3 years. It
in 2010. It is replacing Implanon in many countries. Other
is a nonbiodegradable implant, which contains 68 mg of
implants, such as Nesterone™ and Capronor™, consisting
etonogestrel. The rod has a length of 40 mm and a diameter
of different progestins, biodegradable rods, pellets, and
of 2.0 mm. This single‑rod implant with etonogestrel
microcapsules remain in development. Advancement in
was developed in order to achieve complete inhibition of
this area has also produced male contraceptive implants
ovulation during the total duration of use. A daily release rate
MENT acetate that contains 7α‑methyl‑19‑nortestosterone,
of approximately 30 μ getonogestrel inhibited ovulation in the
although still undergoing approval processes.
majority of women and within 8 h of insertion, etonogestrel
levels are sufficient to provide contraceptive protection.[13] A
Prevalence and Types of Implants continuous release of etonogestrel is maintained for 3 years.
The prevalence of use has remained persistently low despite Within 1 week after removal etonogestrel is no longer
its overwhelming benefits and effectiveness. Contraceptive detectable in human serum.[14] It is very effective and safe,[15,16]
prevalence in Nigeria is 15.1% and implants accounts for only with a the cumulative pearl index ranging from 0 to 0.38.[17,18]
0.4%.[6] Ghana has a contraceptive prevalence of 17% with also a There is no significant difference in pregnancy rates between
very low implant use.[7] In Great Britain, in 2008, 1–2% of women etonorgestrel and LNG implants.[19]
of childbearing age were using the implant.[8] A lot of countries
are yet to start using contraceptive implants and countries that Nexplanon (Implanon NXT): These are single‑rod
have succeeded in raising the prevalence beyond 3% are Burkina contraceptive implants with special applicator for easier
Faso, Colombia, Ethiopia, Norway, and Rwanda.[9] and safe insertion. Each rod measured 40 mm × 2 mm, it
is embedded with 68 mg of etonorgestrel (formerly called
Implants can be biodegradable/nonbiodegradable, LNG/ 3‑ketodesogestrel) and covered by a 0.6 mm rate‑controlling
etonorgestrel based or female/male implants. Female ethylene‑vinyl acetate membrane. Nexplanon also contains
implants include Norplant, Norplant‑2 (Jadelle), Implanon, 15 mg barium sulfate making the rod radiopaque and this
Nexplanon, and Capronor. Contraceptive implants differ aids easy removal. It is as effective as Implanon.[20] This has
based on the progestin content and whether they are replaced the Implanon in most developed countries.
degradable or nondegradable. Norplant and Jadelle contained
LNG that is a second generation progestin whereas Implanon Capronor: It is a biodegradable polymer system for the
and Nexplanon contained etonorgestrel that is a third sustained subdermal delivery of contraceptive steroids. It is
generation progestin. a 4‑cm rod made of a polycaprolactone capsule containing
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Kolawole, et al.: Review of contraceptive implants in southwest Nigeria

21.6 mg of LNG.[21] It provides 1‑year contraception, but it is use.[24] Risks include abnormal uterine bleeding that is the
not currently in routine use. most common cause of discontinuation, skin atrophy at the
site of insertion, acne, impalpable implants, neurovascular
Nestrone: It is a single‑rod implant containing 93 mg of injury, fractured implants. The implant should be removed
nestrone (16‑methylene‑17‑acetoxy‑19 norprogesterone), when pregnancy occurs with an implant in situ. There is
which releases about 40 µg of nestrone per day. Duration of no evidence of harm to the woman, the progress of her
effectiveness is 2 years. pregnancy, or the fetus if pregnancy occurs while using an
implant.[29]
MENT®: Subdermal Implants for Men: Male contraceptive
methods under development at the population council rely Ovulation returns within 3 weeks of implant removal in more
on MENT® acetate (7α‑methyl‑19‑nortestosterone),[22] a than 90% of women.[30] Return to fertility after discontinuation
year implant that is placed under the skin of the upper arm. of implants is no different from other contraceptive methods,
MENT is created from a synthetic steroid that resembles excluding injectables.[30] Pregnancies, whether delivered,
testosterone. If approved by regulatory authorities, MENT miscarried, terminated, or ectopic, all have associated
would be the first long‑acting reversible male contraceptive. costs. Pregnancies averted result in cost savings. Use of the
progestin‑only implant is cost‑effective at 1 year of use.[3] The
Mode of Action, Drug Interactions, and Medical implant is more cost‑effective than even the contraceptive
Eligibility pills.[31]

The primary mode of action of all subdermal implants is to Situation in Nigeria

prevent ovulation.[23] Secondary modes of action include
prevention of sperm penetration of the cervical mucus and Contraceptive implants require the technicality of insertion
prevention of implantation by thinning the endometrium.[23] The and removal necessitating the provision only in hospital
contraceptive efficacy of the progestin‑only implant is reduced setting where the trained personnel are available. Some
by enzyme‑inducing drugs such as some antiepileptic drugs, of these centers are not available in every community and
some antibiotics such as rifampicin, and antiretroviral therapy.[23] in communities with such centers; some are not within
the reach of the clients. Although the cost of inserting an
There are no age restrictions for use of contraceptive implant at the teaching hospital in Ile Ife is 500 naira, it is
implants, thus its use spans across all ages. There are a up to 10 thousand naira in some private hospitals within Ile
few medical conditions for which the risks of implant use Ife. There is also aversion for the minor surgical procedure
generally/usually outweigh the advantages, as defined by involved in its insertion whereas some religious groups still
the WHO Medical Eligibility Criteria.[24] These include severe vehemently reject the idea of modern contraceptive methods.
hepatic disease, women taking liver enzyme‑inducing drugs, Egede et al.[32] and Orji et al.[33] concluded from their study
ischemic heart disease or stroke, current or past history of that there is a mismatch between awareness of contraceptive
breast cancer, and in cases of undiagnosed vaginal bleeding. options, approval of use, and actual use that means there
is a high and widespread awareness but low utilization.
Benefits, Effectiveness, Risks, and Cost Uptake of implants is only 2.3%, 3.3%, 3.6%, 4.1%, and 4.3%
of the total number of clients seen at the family planning
The overall pregnancy rate reported in the National Institute clinics in Ile Ife,[34] Oshogbo,[35] Ilorin,[17] Port Harcourt,[36]
for Health and Care Excellence guideline is less than 0.1% and Ibadan,[37] respectively. This is in contrast to 11.1% in
over the course of 3 years.[3] For women who have undergone Lagos,[38] 13.4% in Jos,[16] and 55.8% in Sokoto,[39] where it is
female sterilization, the lifetime percentage rate is 0.5%,[25] the most predominant method of contraceptive chosen by
and for men undergoing vasectomy, the corresponding figure new clients. Level of education, awareness, and effectiveness
is 0.05%.[26] Although ovulation is occasionally observed of Implanon has been adduced for this increase.[38] Barriers
in the 3rd year of use,[27] the implant remains a highly to use of this effective modern contraceptive option include
effective contraceptive throughout this time because of the lack of access, cultural factors, religion, and opposition to use
secondary modes of action. Improvement in endometriosis, by partners or family members, fear of risks and side effects
dysmenorrheal, and ovulatory pain have been noted with of contraceptives, educational level, and socioeconomic
implants when there is no underlying pathology.[28] status of the woman. Oye‑Adeniran et al.[40] found that
patent medicine shops were the most common sources of
There is no increased risk of venous thromboembolism, contraceptive products accounting for why implants were
myocardial infarction, stroke, and breast cancer with implant not routinely used, whereas the major source of information

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Kolawole, et al.: Review of contraceptive implants in southwest Nigeria

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rod contraceptive implant. J Obstet Gynecol India 2011;61:422.
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15. Aisien A, Enosolease M. Safety, efficacy and acceptability of implanon
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Conclusion and Recommendations Benin Teaching Hospital. Niger JClin Pract 2010;13.
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the uptake is still very low in the southwestern part of acceptability in Jos, North‑Central Nigeria. Niger JClin Pract 2008;11.
17. Balogun O, Olaomo N, Adeniran A, Fawole A. Implanon sub‑dermal
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11 international clinical trials. FertilSteril 2009;91:1646‑53.
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Marintcheva‑Petrova M. Nexplanon, a radiopaque etonogestrel implant
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noncomparative multicenter trial. Am JObstetGynecol 2012;207:388.
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