The case of the missing implant: the importance of adhering to insertion guidelines

The case of the missing implant: the importance of adhering to insertion


U. Ernst

Organon Germany, Oberschleiheim, Germany

Introduction: Implanon, a single-rod subdermal contraceptive, releases

68 mg etonogestrel over three years. It was introduced in Germany in June 2000.

This case report describes the incorrect insertion of Implanon, by a

gynecologist trained in the procedure, in Germany in October 2002.

Case description: A 39-year old woman visited her gynecologist for

insertion of Implanon. The insertion was performed whilst the patient was in a

sitting position with the arm hanging downwards. The insertion was made in the

lower third of the upper arm right on the ventrolateral side of the biceps

muscle and not in the recommended area: subdermally in the middle third of the

upper arm in the medial groove between biceps and triceps muscles. Blood flow at

the insertion site was copious during the procedure, especially when the needle

was removed. Following insertion, the implant was not palpable. Attempts made to

localize the implant firstly by ultrasound and then with magnetic resonance

imaging (MRI) were not successful. Additional investigations, performed on the

assumption that the implant might have been inserted intravasally, also failed

to localize the implant. These included MRI of the vessels of the right upper

arm and the right shoulder/clavicle region, the heart and nearby vessels,

echocardiography of the atria and ventricula of the heart, pulmonary artery

angiography, phlebography of the lung veins and the vena cava superior. In

addition to the attempts to locate the implant’s physical presence, detection

of etonogestrel (ENG) was carried out to establish whether the implant was in

the body or not. ENG detection was positive, at a level of 308 pg/ml, which is

in the normal range of an implant in situ. An expert in the field of heart and

lung surgery was consulted as to the possible consequences of an implant

circulating in the thoracic vessel system. He concluded that if the implant had

been carried along with the blood flow, it could eventually become jammed in a

branch of the pulmonary artery, possibly up to a peripheral branch of a lung

segment, where it is unlikely to cause serious damage.

Discussion: This is the first case where the location of a

non-palpable Implanon rod after insertion and positive ENG detection could not

be clarified. Whilst so far there is no direct proof that the implant is in the

vessel system, the procedures followed during this insertion, which deviate from

the official insertion instructions for Implanon, lead to the hypothesis that

the implant was inserted intravasally. This case could and should have been

prevented by the careful following of the guidelines of the package leaflet. The

importance of adhering to those recommendations therefore cannot be stressed


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