Dr Elliman1 asked whether other clinicians had experience of damaged implants. Dr Rekers2 replied that breakage is rare and would not alter contraceptive efficacy.

I have removed damaged implants from seven patients since June 2011, all of which were sited correctly. Two patients underwent subsequent removal of a second damaged implant. All the patients were aware of abnormality, but only one remembered trauma. One had positive home pregnancy tests from 3 days after implant removal, suggesting method failure.

The first patient requested exchange of a bent Nexplanon^® at 10 months. She described an injury 4 months previously. She felt unwell and had experienced recent heavy bleeding in place of the initial amenorrhoea. Pickard and Bacon3 described bleeding in association with a damaged implant. I chose incision over the bend but found that the two halves were attached by the rate-limiting membrane.

The second patient attended for Nexplanon exchange at 5 months, describing ‘popping’ in her arm and a broken implant. This implant was completely fractured. Both halves popped out easily via an incision over the break, which I also used for reinsertion. Five months later the patient requested removal because of burning pain at the implant site. A colleague removed the implant and recorded that it was bent in several places. The patient reported three positive pregnancy tests during the next 7 days followed by heavy bleeding with clots. A pregnancy test 8 days after implant removal was negative.

The third patient requested Nexplanon exchange for bending at 8 months. The usual removal technique revealed two incomplete fractures of the core. I used the same incision for reinsertion. Three days later the patient experienced pain and again found abnormal bending. She demanded immediate removal. I acquiesced and found minor cracking of the implant core.

I performed early removal because of a bent Nexplanon for a fourth patient 15 months after insertion.

Two further patients were aware of Nexplanon damage but attended for removal because they wanted to get pregnant. One attended at 16 months and underwent the usual removal technique, which revealed two central bends. The other woman who attended at 24 months had a complete break in her implant that required a second incision for the proximal half. I had quickly checked that the implant was palpable and hadn't enquired about possible damage. When the first half popped out the patient confirmed that she had suspected the implant was broken for many months. These were the only two implants with identical batch numbers.

A final patient only reported her bent Implanon^® when attending for routine exchange after 3 years.

All the cases I have described except the final one involve Nexplanon. In my previous years of experience with Implanon I had been unaware of any cases involving implant damage. Structurally Nexplanon differs from Implanon by the addition of 3% barium. Unlike Implanon, Nexplanon cannot slip in its inserter, and errors during the insertion process seem unlikely to explain the apparent increased frequency of damage.

I would be interested to know whether other Journal readers have noticed an increase in damaged implants since Nexplanon replaced Implanon.

I routinely use the same incision for reinsertion, but having two patients attend with recurrent damage might suggest that this practice should be avoided.

Only two of these damaged implants were completely broken. Doshi4 suggested that taking an X-ray of the bent Nexplanon might help clarify the situation. In practice my patients were unhappy with the bent device and wanted it removed even if it wasn't fractured. Removing partially fractured implants using the usual pop-out technique is the simplest and least traumatic method of removal but it does carry the risk of needing a second small incision if the implant is truly broken. An incision over the centre of an implant that is only bent needs to be a little larger in order to remove the implant in its bent form. I would suggest careful enquiry and examination, and unless the implant is clearly in two pieces I would recommend that the usual pop-out removal technique be employed.