What counseling is recommended after Nexplanon (etonogestrel implant) removal?

Counseling After Nexplanon Removal

After Nexplanon removal, patients should be counseled about immediate return to fertility, alternative contraceptive options, and the need for immediate initiation of a new method if pregnancy prevention is desired.

Return to Fertility

• Fertility returns rapidly after Nexplanon removal, with no delay in the ability to conceive
• Studies show high cumulative conception rates following implant removal:
  • 80.3% of women who discontinued to plan pregnancy conceived within one year 1
  • 88.3% conceived within two years 1
• Patients should be informed that they can become pregnant immediately after removal if no alternative contraception is used

Contraceptive Options After Removal

Immediate Contraceptive Counseling

When counseling about contraceptive options after Nexplanon removal, use a tiered approach starting with the most effective methods 2:

1. Long-Acting Reversible Contraception (LARC)

   • Another etonogestrel implant (Nexplanon) - >99% effective (0.05% failure rate) 3
   • IUDs:
     • Hormonal IUD - >99% effective (0.1-0.2% failure rate) 3
     • Copper IUD - >99% effective (0.8% failure rate) 3

2. Moderately Effective Methods

   • Injectable contraception (DMPA) - 94-97% effective 3
   • Combined hormonal contraceptives (pills, patch, ring) - 91-95% effective 3
   • Progestin-only pills - 91-95% effective 3

3. Less Effective Methods

   • Male condoms - 86% effective with typical use 3
   • Female condoms - 79% effective with typical use 3
   • Fertility awareness methods - 75% effective with typical use 3

Timing of New Method Initiation

• If continued contraception is desired, a new method should be started immediately upon Nexplanon removal to prevent unintended pregnancy
• For hormonal methods:
  • Combined hormonal contraceptives (pills, patch, ring) should be started within 5 days of removal with no need for backup method if started immediately 2
  • If starting >5 days after removal, use backup method for 7 days 2
  • Progestin-only pills should be started immediately with backup method for 2 days 2

Special Considerations

Bleeding Pattern Counseling

• Inform patients that bleeding patterns will change after Nexplanon removal
• If switching to another hormonal method, counsel about expected bleeding patterns with the new method 2
• If not using hormonal contraception, regular menstrual cycles typically return within 3 months

Potential Side Effects of Previous Implant

• Discuss resolution of any Nexplanon-related side effects
• Most side effects resolve quickly after removal
• The most common adverse reaction with Nexplanon is change in menstrual bleeding patterns, which should normalize after removal 4

Procedural Complications

• Removal complications are rare (successful removal rate of >99.9%) 5
• The most common challenge during removal is encasement of the implant within fibrotic tissue 5
• Reassure patients that complications during removal are uncommon when performed by trained clinicians

Follow-up Recommendations

• Schedule follow-up if starting a new contraceptive method to assess satisfaction and address any concerns
• If planning pregnancy, consider preconception counseling
• If pregnancy is not desired, emphasize the importance of consistent use of the chosen contraceptive method

Common Pitfalls in Post-Removal Counseling

1. Failure to emphasize immediate return to fertility

   • Many patients incorrectly assume there is a delay in fertility return
   • Stress that pregnancy can occur immediately after removal

2. Inadequate counseling about new method initiation timing

   • Be specific about when to start new methods and when backup is needed
   • For combined hormonal methods started >5 days after removal, emphasize the need for 7 days of backup contraception 2

3. Not addressing patient concerns about previous side effects

   • Acknowledge any side effects experienced with Nexplanon
   • Explain how these may differ with alternative methods

By providing comprehensive counseling after Nexplanon removal, healthcare providers can help patients make informed decisions about future contraception or family planning, ensuring continuity of care and preventing unintended pregnancies.