What is the proper procedure for implanting a Nexplanon (etonogestrel implant)

Nexplanon Implantation Procedure

Nexplanon must be inserted subdermally into the inner aspect of the non-dominant upper arm, 6 to 8 cm above the medial epicondyle of the humerus, by a healthcare provider who has completed the manufacturer's required training program. 1

Pre-Insertion Requirements

Provider Training

• All healthcare providers must complete the Nexplanon clinical training program before performing insertions or removals 2, 3
• Proper training is essential to prevent complications such as nerve injury, deep insertion, or non-insertion 2, 4

Pre-Insertion Assessment

• No routine examinations or tests are required before insertion in healthy women 1
• Baseline weight and BMI measurement may be useful for monitoring over time 1
• Confirm the patient is not pregnant using standard pregnancy assessment criteria 1
• Pelvic examination is not necessary for safe initiation 1

Insertion Technique

Anatomical Positioning

• Insert on the inner side of the non-dominant upper arm, 6-8 cm above the elbow (medial epicondyle) 1
• This specific location minimizes risk of nerve injury, particularly to the medial cutaneous nerve of the forearm 4
• The standard arm location should be used; alternative sites (scapular region) are only for exceptional circumstances in patients with psychiatric disorders at risk for self-removal 5

Procedure Duration

• Insertion takes approximately 1 minute when performed correctly 1
• The device contains barium sulfate making it radiopaque and visible on imaging 1

Timing of Insertion

Regular Menstrual Cycles

• If inserted within the first 5 days of menstrual bleeding: no backup contraception needed 1
• If inserted ≥6 days after menstrual bleeding started: use backup contraception for 7 days 1

Amenorrhea (Non-Postpartum)

• Can be inserted anytime if reasonably certain patient is not pregnant 1
• Requires 7 days of backup contraception 1

Postpartum Insertion

• Breastfeeding women: Can insert anytime postpartum; no backup needed if <6 months postpartum, amenorrheic, and fully/nearly fully breastfeeding 1
• Non-breastfeeding women: Can insert immediately postpartum; if ≥21 days postpartum without menses return, requires 7 days backup contraception 1

Post-Abortion

• Can insert within first 7 days including immediately after abortion 1
• No backup needed if placed at time of surgical abortion; otherwise requires 7 days backup contraception 1

Switching from Another Method

• Can insert immediately without waiting for next menstrual period 1
• If >5 days since menstrual bleeding started: requires 7 days backup contraception 1
• When switching from IUD with recent intercourse: consider retaining IUD for 7 days after implant insertion, or using emergency contraception at IUD removal 1

Common Pitfalls to Avoid

Insertion Errors

• Incorrect insertion (non-insertion, partial insertion, or deep insertion) occurs in 12.6 per 1000 insertions 2
• Deep insertion into muscle tissue is the most serious complication, potentially requiring surgical removal 2
• Direct contact with nerves (particularly medial cutaneous nerve) causes forearm pain and hypoesthesia 4

Prevention Strategies

• Strict adherence to anatomical landmarks (6-8 cm above medial epicondyle) 1
• Use of the redesigned Nexplanon applicator (versus older Implanon) improves insertion accuracy 4
• Immediate post-insertion palpation to confirm subdermal placement 2

Post-Insertion Considerations

Expected Outcomes

• Failure rate <1% with proper insertion 1, 6
• Effective for 3 years 1, 3
• Most common adverse reaction is change in menstrual bleeding patterns 3
• Pins and needles/numbness in arm/hand/fingers is the most common patient-reported event, typically transient 2

Removal Planning

• Must be removed by end of third year 3
• Removal typically accomplished in under 5 minutes 1
• Encasement in fibrotic tissue is the most common removal challenge 2
• Rapid return to fertility after removal 3