Twin Pregnancy Rate After Nexplanon Removal
The probability of twin pregnancy after Nexplanon removal is not increased compared to the general population; fertility returns rapidly to baseline rates, and twin pregnancy risk remains at the standard population rate of approximately 1-3% depending on maternal factors.
Return to Fertility After Nexplanon Removal
Fertility returns immediately after Nexplanon removal, with no delay in ovulation or conception. 1
- Women experience a rapid return to fertility once the implant is removed, with ovulation resuming promptly 1, 2
- In studies of similar progestin-only implants (Norplant), the cumulative probability of conception was:
- 25% at 1 month
- 49% at 3 months
- 73% at 6 months
- 86% at 12 months after removal 3
- No correlation exists between the length of implant use and the interval from removal to conception 3
Twin Pregnancy Risk: No Evidence of Increased Incidence
Nexplanon removal does not increase the risk of twin pregnancy. The mechanism of action—primarily ovulation suppression—does not create a "rebound" effect that would increase multiple ovulation after discontinuation.
- The etonogestrel implant works mainly by suppressing ovulation, not by altering ovarian follicular development in ways that would predispose to multiple ovulation after removal 2, 4
- Large prospective studies of pregnancy outcomes after Nexplanon use show normal singleton pregnancy rates with no documented increase in twin gestations 5
- In the NORA study of 7,364 Nexplanon users, pregnancy outcomes after removal were consistent with expected population rates, with no signal for increased twinning 5
Expected Twin Pregnancy Rate
The baseline twin pregnancy rate in the general population is approximately 1-3%, influenced primarily by:
- Maternal age (higher risk >30-35 years) 6
- Family history of dizygotic twins
- Ethnicity (higher in African populations, lower in Asian populations)
- Use of assisted reproductive technology (which dramatically increases twin rates to 20-30%) 6
After Nexplanon removal, women return to their baseline population risk—there is no pharmacologic or physiologic mechanism that would elevate twin pregnancy rates above this baseline.
Clinical Counseling Points
- Counsel patients that fertility returns immediately after removal, so contraception should be initiated immediately if pregnancy is not desired 1
- No waiting period is necessary before attempting conception after Nexplanon removal 1, 3
- Twin pregnancy risk after Nexplanon removal is identical to the patient's baseline population risk—not elevated
- Women over 30 years may experience slightly longer time-to-conception intervals, but this does not affect twin pregnancy rates 3