Case

Kristy, a 17-year-old girl, presents to clinic, having previously had a discussion of her contraceptive options with you. She is sexually active with her boyfriend and does not want to become pregnant. She feels that an implant would suit her and wishes to discuss it further as she has some concerns. Her friend had an implant, but when she requested a removal, she had to be referred to a specialist as the implant was impalpable. Her friend’s experience is putting Kristy off and she doesn’t really understand how it could have happened.

What to do next

Kristy trusts you and is seeking guidance in this decision. After you have established rapport with her, you thank her for returning to discuss her concerns. It is important to validate her concerns so that she understands you will not judge her for sharing them with you, and that she does not need to edit her conversations with you. This leaves the door open for further conversation on the topic. A next step is to ask her to tell you more about what she has heard from her friend and other people who may influence her choices.

After Kristy has shared her concerns, you revisit her motivation for preventing pregnancy and assess how important it is to her. Two approaches for assessing pregnancy intention are One Key Question and the PATH (Parenthood/Pregnancy, Attitude, Timing, and How important is pregnancy prevention) framework. One Key Question asks, "Would you like to become pregnant in the next year?". The PATH framework questions are: (1) Would you like to have children (more children) someday?, (2) If so, when do you think that would be? and (3) How important is it to you to prevent pregnancy until then? Once you understand that preventing pregnancy is important to Kristy, you are well positioned to start a discussion with her in which you elicit her preferences and priorities regarding contraceptives. It may be helpful to use a motivational interviewing technique and share a reflection with Kristy integrating what you have heard. It might go something like this: "Kristy, what I am hearing is that you were interested in starting the implant after our last conversation but became concerned that what happened to your friend might happen to you. You are sexually active with your boyfriend and you don’t want to become pregnant. You want a method that doesn’t involve you taking something every day, week or month and you aren’t interested in the injectable (shot). You want to talk about the implant and better understand if what happened to your friend is likely to happen to you. Did I get that right? Did I miss anything?"

Having secured Kristy's agreement to proceed, you next share information with her about how rare difficult removals are and that it would be unlikely to happen to her, even though it happened to her friend.5 You explain that after an implant is inserted it is palpated by the fitter and the patient, so they know the location and how it feels. And, if at any time the patient cannot feel her implant, she should alert her HCP because the implant would need to be assessed. It may be reassuring for Kristy to understand that you are connected to skilled specialists who can safely remove a deep implant. You also share with her that you are trained in the anatomy of the arm, experienced in implant insertion, and believe the method to be safe for her. It is important to ask if she has any additional concerns or questions.

After your conversation about safety, you review the features that initially appealed to her and revisit whether she has any additional questions about the method or other methods. You tell her that you are available to her regardless of method choice, and should she choose the implant and be unsatisfied with it you will remove it promptly. In closing, you ask if she’d like to start a contraceptive method today.

Patient outcome

Kristy is relieved to learn that difficult removals are uncommon and that you endorse her use of the implant. She decides to start the implant today. You are reasonably certain she is not pregnant because she has no signs or symptoms of pregnancy and has not had intercourse since the beginning of her period last week. She is keen for immediate insertion of Nexplanon. Shortly thereafter, the implant is placed, and Kristy leaves your office with her chosen contraceptive method and knowing that she can return and speak with you in the future with any sexual and reproductive health questions or concerns she may have.