The commentary by Horga et al.[1] on the consequences of Ceausescu's
attempt to ban abortion in Romania is a stark reminder of what happens
when women are prevented from accessing safe and legal means to end
problem pregnancies. In short, they end their pregnancies using means that
are unlawful and/or unsafe, sometimes with tragic consequences.
Although it is difficult to compare any country today with the
repre...
The commentary by Horga et al.[1] on the consequences of Ceausescu's
attempt to ban abortion in Romania is a stark reminder of what happens
when women are prevented from accessing safe and legal means to end
problem pregnancies. In short, they end their pregnancies using means that
are unlawful and/or unsafe, sometimes with tragic consequences.
Although it is difficult to compare any country today with the
repressive, restrictive climate of Romania in the 1960s and 1970s, a
reminder of the contribution that adequate birth control, including
abortion, makes to women's health is important. Politicians in Ireland -
and the UK, since abortion is still outlawed in the Northern Ireland
counties that it governs - would do well to take note.
The recent death of a woman who was denied a pregnancy termination in
Ireland[2] has focused international attention on its abortion ban. One
might ask why, when one considers Romania, there have not been more deaths
in Ireland? The answer is simple. Although abortion is unlawful in
Ireland, Irish women have found their own ways of accessing services.
For thousands of Irish women, the path to an abortion involves a
relatively cheap flight to Britain and treatment provided by a not-for-profit clinic run by a charity. At British Pregnancy Advisory Service
(bpas) clinics, especially in Liverpool, Birmingham and London, Irish
visitors are so 'normal' that a special range of literature is provided,
explaining how to care for themselves as they travel home.
Other women rely on the internet to obtain medicines that are safe
for them to use but illegal to obtain. Clearly, there are risks with
internet supply, not least that the medication may not be authentic, and
could even be harmful. Internet sites such as 'Women on Web'
(https://www.womenonweb.org/) have become a vital source of safe
medication for women living where safe, legal abortion is unavailable. And
the widespread availability of the abortifacient misoprostol as treatment
for gastric ulcers is another lifeline, especially where it is available
in local pharmacies.
Women still die from abortion bans. International agencies publish
estimates routinely. Governments record their horror and pledge to make
motherhood safer. At the London Summit on Family Planning in July 2012,
the Prime Minister responded to estimates that an unplanned pregnancy is
conceived every 10 seconds by announcing £500 million in aid to increase
international access to contraceptives.[3] He told government
representatives from around the world: "Women should be able to decide
freely, and for themselves, whether, when and how many children they have
... When a woman is prevented from choosing when to have children it's not
just a violation of her human rights, it can fundamentally compromise her
chances in life, and the opportunities for her children."[4]
Yet in Northern Ireland and Ireland, women are denied that choice
because they are denied access to abortion. European politicians find it
easy to understand the importance of safe contraception and abortion in
countries far away; they find it less easy to understand the importance of
reproductive choice in their own countries. Romania is a good European
example of why abortion bans should be regarded as being as perverse and
as archaic as the rest of Ceausescu's policies.
References
1 Horga M, Gerdts C, Potts M. The remarkable story of Romanian
women's struggle to manage their fertility. J Fam Plann Reprod Health Care
2013;39:2-4.
2 Houston M. Investigations begin into death of woman who was refused
an abortion. BMJ 2012;345:e7824.
3 Prime Minister's Speech on Family Planning. 11 July 2012.
http://www.number10.gov.uk/news/prime-ministers-speech-on-family-planning/
[accessed 15 January 2013].
4 Tran M. Rich countries pledge $2.6bn for family planning in global
south. 11 July 2012. http://www.guardian.co.uk/global-
development/2012/jul/11/rich-countries-pledge-family-planning-women
[accessed 15 January 2013].
I read with interest Dr MacGregor's letter[1] regarding the unusual
shape of a Mirena intrauterine system (IUS) following removal. From the
photograph it would appear that the capsule has become displaced and the
arms of the device enclosed within it.
We have seen a case of complete detachment of the capsule from the
frame, with unrecognised retention of the capsule within the uterine
cavity. This was only reco...
I read with interest Dr MacGregor's letter[1] regarding the unusual
shape of a Mirena intrauterine system (IUS) following removal. From the
photograph it would appear that the capsule has become displaced and the
arms of the device enclosed within it.
We have seen a case of complete detachment of the capsule from the
frame, with unrecognised retention of the capsule within the uterine
cavity. This was only recognised at hysteroscopy for investigation of
subsequent infertility.
This was described in the form of a letter to the British Journal of
Obstetrics and Gynaecology in 2008.[2]
It would seem prudent to check the integrity of the IUS at removal.
References
1 MacGregor A. An unusual shaped IUS. J Fam Plann Reprod Health Care
2013;39:64.
2 Forrest A, Amarakone I, Lord J. Retained hormone release capsule
following removal of Mirena intrauterine system. BJOG 2008;115:130-131.
I read the article by Briggs and colleagues[1] with interest as it
is, to my knowledge, the only study to assess the impact of the
implementation of the UK Medical Eligibility Criteria on general practice
prescribing of combined hormonal contraceptives (CHCs) in the UK. However,
I have a study limitation.
As the authors have stated, oral contraception can be accessed on
prescription from a general practitioner (...
I read the article by Briggs and colleagues[1] with interest as it
is, to my knowledge, the only study to assess the impact of the
implementation of the UK Medical Eligibility Criteria on general practice
prescribing of combined hormonal contraceptives (CHCs) in the UK. However,
I have a study limitation.
As the authors have stated, oral contraception can be accessed on
prescription from a general practitioner (GP) and these data are captured
in the therapy table in the General Practice Research Database (GPRD) -
the data source used by the investigators. However, CHCs can also be
obtained from National Health Service contraception clinics and these data
are not recorded in a patient's prescription history in GPRD. Women
registered with GPRD who have obtained their CHC from contraception
clinics will therefore not be identified as CHC users as part of this
study, leading to an underestimation in the number of CHC users aged 15-49
years. An estimated 413 000 women in England and 20 000 women in Wales
received oral contraception from a contraceptive clinic in 2011/2012 and
2010/2011 respectively.[2][3] Although these figures are not specifically
for CHCs, they illustrate that community contraceptive clinics play a
substantial role in the provision of contraception to women of
childbearing age.
In addition, those patients prescribed CHCs by their GP, and
therefore included in the study, are not likely to be sufficiently
representative of those patients who are prescribed CHCs from clinics. The
National Statistics Opinion Survey conducted during 2008/2009 showed that
during the 5 years prior to interview, a higher percentage of patients
aged 16-19 years accessed contraception through a community contraception
clinic rather than their GP or community practice nurse.[4] Conversely, a
larger percentage of older women obtained family planning services from
their GP.[4] As the patients accessing community contraceptive services
are in general younger, they may also be less likely to have certain
Category 3 or 4 risk factors (e.g. current smokers and previous smokers
aged 35 years or over). Furthermore, patients with risk factors such as
hypertension, migraine, stroke, ischaemic heart disease, dyslipidaemia and
migraine may be more likely to obtain contraception from their GP while
being monitored for these conditions.
The impact of this limitation is likely to have influenced the
estimation of the number of women using a CHC with a Category 3 or 4 risk
factor in the whole UK population.
References
1. Briggs PE, Praet CA, Humphreys SC, Zhao C. Impact of UK Medical
Eligibility Criteria implementation on prescribing of combined hormonal
contraceptives. J Fam Plann Reprod Health Care 2013;00:1-7.
doi:10.1136/jfprhc-2012-100376 [published Online First 7 January 2013].
2. Health and Social Care Information Centre, Lifestyles Statistics.
NHS Contraceptive Services: England 2011/12 Community Contraceptive
Clinics. Leeds, UK: NHS, 2012. http://www.ic.nhs.uk/article/2021/Website-
Search?productid=9063&q=NHS+Contraceptive+Services%3a+England&sort=Relevance&size=10&page=1&area=both#top
[accessed 12 January 2013].
3. Statistics for Wales. NHS Community Contraceptive Services in
Wales, 2011-12. Cardiff, UK: Welsh Government, 2012.
http://wales.gov.uk/topics/statistics/headlines/health2012/121129/?lang=en
[accessed 12 January 2013].
4. Lader D. Opinions Survey Report No. 41. Contraception and Sexual
Health, 2008/09. Newport, UK: Office for National Statistics; 2009.
http://www.statistics.gov.uk [accessed 12 January 2013].
Conflict of Interest:
The author is currently in receipt of a PhD Studentship from Cardiff University and is employed as a pharmacist researcher by a research consultancy that receives funding from pharmaceutical companies. In addition, the author is currently employed on a part-time basis as a community pharmacist for a large health and beauty group.
I read the letter on 'Early implant removal: an ethical dilemma' by
Bari et al.[1] in the January 2013 issue of the Journal with interest, a
great feeling of disappointment and I shared the feelings of alarm with
the authors. The piece reported a 29-year-old woman who was so
dissatisfied with her subdermal implant that she attempted removal herself
without anaesthetic and she broke the device. She had requested removal
f...
I read the letter on 'Early implant removal: an ethical dilemma' by
Bari et al.[1] in the January 2013 issue of the Journal with interest, a
great feeling of disappointment and I shared the feelings of alarm with
the authors. The piece reported a 29-year-old woman who was so
dissatisfied with her subdermal implant that she attempted removal herself
without anaesthetic and she broke the device. She had requested removal
from "several sexual health clinics" but had been turned away.
Refusing removal in this way will surely destroy the reputation of
this method and do great harm to the population of contraceptive seekers,
as well as the distressed user.
Some years back I worked in Indonesia (and several South Asian
countries) where women were often refused early cessation of a
contraceptive method. Consequently, in Indonesia especially, Norplant
developed a reputation for causing a high level of unwanted bleeding and
other undesirable side effects and uptake fell. Surely we must not make
the same mistake again here in Britain?
Reference
1. Bari S, Kulkarni U, Robinson G. Early implant removal: an ethical
dilemma. J Fam Plann Reprod Health Care 2013;39:64.
Conflict of Interest:
None disclosed, although the author does fit subdermal implants and intrauterine devices in general practice in England
On behalf of all the authors I would like to thank Sarah Holden for
her comments[1] on our recently published article.[2]
When designing the study, we recognised that the majority of women
receive their contraception from their general practitioner (GP). Our
study compares the prescribing habits of GPs in 2005 pre-UK Medical
Eligibility Criteria (pre-UKMEC) to those in 2010 (post-UKMEC).
On behalf of all the authors I would like to thank Sarah Holden for
her comments[1] on our recently published article.[2]
When designing the study, we recognised that the majority of women
receive their contraception from their general practitioner (GP). Our
study compares the prescribing habits of GPs in 2005 pre-UK Medical
Eligibility Criteria (pre-UKMEC) to those in 2010 (post-UKMEC).
Whilst the authors realise that this does not reflect total
contraceptive usage in the UK, it does compare women prescribed combined
hormonal contraceptives (CHCs) by their GPs in 2005 to a similar group of
women in 2010. Consequently we presume that we are comparing 'apples' with
'apples' and therefore our conclusion that there was "a reduction in
prescribing of CHCs to higher-risk women after publication of UKMEC, a
large number of women with Category 3 or 4 risk factors are still
prescribed CHCs" is valid and is worth publicising to the reproductive
health clinical community.
References
1. Holden SE. Comment on 'Impact of UK Medical Eligibility Criteria
implementation on prescribing of combined hormonal contraceptives'. J Fam
Plann Reprod Health Care 2013;00:1. doi:10.1136/jfprhc-2013-100627.
2. Briggs PE, Praet CA, Humphreys SC, et al. Impact of UK Medical
Eligibility Criteria implementation on prescribing of combined hormonal
contraceptives. J Fam Plann Reprod Health Care 2013;39:1-7. Published
Online First 7 January 2013. doi:10.1136/jfprhc-2012-100376.
I read with interest Anne MacGregor's letter in the January 2013
issue of the Journal describing the removal of an unusually shaped
intrauterine system (IUS) and asking if others have had similar
experiences.[1]
A couple of years ago I too was alarmed as I removed an IUS through a
slightly tight cervical os and noted an odd shape. On closer inspection
the device was removed intact but as in Dr MacGregor's case t...
I read with interest Anne MacGregor's letter in the January 2013
issue of the Journal describing the removal of an unusually shaped
intrauterine system (IUS) and asking if others have had similar
experiences.[1]
A couple of years ago I too was alarmed as I removed an IUS through a
slightly tight cervical os and noted an odd shape. On closer inspection
the device was removed intact but as in Dr MacGregor's case the hormonal
sheath bad slipped down the plastic shank thus folding in the arms. In
this case, the sheath had actually come much closer to being totally
detached.
At the time I was looking through some back journal issues and
fortuitously came across a letter in the Faculty Journal[2] written in
2009 by Emma Torbe et al. describing two other similar events. Since these
events occurred years apart it cannot be assumed that this was just one
faulty batch of devices, and it would appear that it is something that one
needs to be aware does occasionally happen. It highlights the importance
of examining the device when it is removed and knowing what the original
device was. I have removed quite a few Nova-Ts that have been in situ for
too long and have become 'denuded' of copper. The appearance would be very
similar to a 'denuded' IUS. The difference is important since no action
would be needed in the case of the Nova-T, however further investigation
to locate the missing sheath would be necessary in the case of an IUS.
I have kept the misshapen IUS in a specimen bottle as a training aid!
References
1. MacGregor A. An unusual shaped IUS. J Fam Plann Reprod Health
Care 2013;39:64.
2. Torbe EJV, Eddowes H, Aston K. Missing IUS arms? J Fam Plann
Reprod Health Care 2009;35:131.
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an
emergency contraception (EC) algorithm following the introduction of
ulipristal acetate (UPA), likewise recognising that fitting an
intrauterine device (IUD) was the 'gold standard'. Our ongoing experience
is rather different, however, in that our rates of emergency IUD fitting
have increased since the introduction of our algorithm from 6% to at least
9%...
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an
emergency contraception (EC) algorithm following the introduction of
ulipristal acetate (UPA), likewise recognising that fitting an
intrauterine device (IUD) was the 'gold standard'. Our ongoing experience
is rather different, however, in that our rates of emergency IUD fitting
have increased since the introduction of our algorithm from 6% to at least
9%.
Within the Department of Sexual and Reproductive Healthcare in
Aneurin Bevan Health Board (South Wales), 6% (17/270) of clients leaving
the clinic with a method of EC in 2011 had an IUD fitted. Our service is
different to the one in Cambridge in that our clients can usually have an
IUD fitted on the day of presentation providing there is an IUD fitter in
clinic. Thus a second appointment is not needed.
Although there is no recognised standard for the percentage of
emergency IUDs fitted, Schwarz et al.[2] found that 12% of women attending
a walk-in clinic for either pregnancy testing or EC would consider same-day fitting of an IUD, and a further 22% expressed interest in having
further information about the IUD, suggesting that our emergency IUD
insertion rates could be improved. We therefore ran a teaching session in
January 2012 to emphasise the efficacy and benefits of emergency IUDs to
nursing staff, and between March and May 2012 introduced our algorithm for
EC, including the use of UPA. Our algorithm is similar to that used in
Cambridge but we consider the high risk time for conception to be Days 10-15 of the cycle, and our algorithm is designed so that staff must record
that they have discussed the emergency IUD. In the 3 months following the
intensive teaching programme our rate of emergency IUD use increased to
11.8%. Disappointingly, however, for the 9 months to the end of 2012 the
rate dropped to an average of 9%.
We audited the notes of all clients given EC between May and July
2012 and found that 31% of clients had been inaccurately recorded as
unsuitable for the IUD. In a further 11% of cases we could not assess
suitability for an IUD from the information provided. Consequently,
further teaching was undertaken to explain to staff when clients may have
an emergency IUD fitted, and the clinical proforma was amended so that
staff had to give reasons why the client was unsuitable for an IUD.
An audit for the first 3 months of 2013 demonstrates a small increase
in emergency IUD use to 10.5%. As well as being encouraging, this suggests
that clinician advice to clients is influential in their choice of EC. As
many of our clients have little or no knowledge of the emergency IUD[3,4]
and a possibly inflated estimate of the effectiveness of oral EC,[5] it is
also incumbent upon the clinician to give appropriate risk management
advice.[6]
In summary, our experience of introducing a new EC pathway that
includes UPA has been an increase in the rate of clients using emergency
IUD contraception from 6% to at least 9%. It is noteworthy that our
initial rate of emergency IUD use was initially far lower than in
Cambridge but our current endpoint is similar. We will continue auditing
emergency IUD use to see if we can sustain, or improve on, our current
usage. If this small effect were to be replicated nationally, this would
constitute a clinically important increase in long-acting reversible
contraception use and more cost-effective contraception[7] - a definite
bonus in these financially stretched times.
References
1. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients' choices. J
Fam Plann Reprod Health Care 2013:39:1-7. doi.10.1136/jfprhc-2012-100495.
2. Schwarz EB, Kavanaugh M, Douglas E, et al. Interest in
intrauterine contraception among seekers of emergency contraception and
pregnancy testing. Obstet Gynecol 2009;113:833-839.
3. Wright RL, Frost CJ, Turok DK. A qualitative exploration of
emergency contraception users' willingness to select the copper IUD.
Contraception 2012;85:32-35.
4. Lader D. Opinions Survey Report No. 41, Contraception and Sexual
Health 2008/9. http://www.ons.gov.uk/ons/rel/lifestyles/contraception-and-
sexual-health/2008-09/2008-09.pdf [accessed 24 April 2013].
5. Bharadwaj P, Saxton J, Mann SC, et al. What influences young women
to choose between the emergency contraceptive pill and an intrauterine
device? A qualitative study. Eur J Contracept Reprod Health Care
2011;16:201-209. doi:10.3109/13625187.2001.565891.
6. Braybrook S, Ahmed H, Cogswell C, et al. Communicating risk about
emergency contraception. Gynaecology Forum 2013;(in press).
7. National Institute for Health and Clinical Excellence. Long-acting
Reversible Contraception. 1995.
http://guidance.nice.org.uk/CG30/Guidance/pdf/English [accessed 24 April
2013].
Conflict of Interest:
The Department of Sexual and Reproductive Healthcare in Aneurin Bevan Health Board has received sponsorship for clinical meetings from Durbin, Bayer Healthcare, HRA Pharma and MSD Women's Health. Dr Cogswell has received honoraria from MSD Women's Health and Bayer Healthcare. Dr Lipetz has received honoraria from Bayer Healthcare and MSD Women's Health.
I read with interest the article Garrett and Kirkman et al.[1] wrote
on the limited success of the pilot telemedicine sexual health service and
their reflections on needing more advice from what young people thought to
have got it right.
A 2008 UNICEF statement entitled 'Young People: Partners for
Health'[2] written by an international group of young people states:
"Young people need to be at the forefront in the...
I read with interest the article Garrett and Kirkman et al.[1] wrote
on the limited success of the pilot telemedicine sexual health service and
their reflections on needing more advice from what young people thought to
have got it right.
A 2008 UNICEF statement entitled 'Young People: Partners for
Health'[2] written by an international group of young people states:
"Young people need to be at the forefront in the development of primary
health efforts" and urges all to act upon their recommendations so that
young people get involved as partners in primary health care.
We have recently started trying to work more closely with young
people at our practice. They have explained to us why some of our
"excellent" ideas would not work for young people and have given us
interesting and innovative solutions to problems.
The 2012 Report of the Children and Young People's Health Outcomes
Forum[3] highlights the benefits of involving young people in service
design. It comments on the fact that "public services that involve and
listen to children and young people find the result to be better services,
better informed consumers and overall, better value for the investment".
In this new era of Clinical Commissioning Groups and a cash-strapped
health service, the findings of Garrett and Kirkman[1] are an important
lesson for us all to take note of and learn from.
References
1. Garrett CC, Kirkman M. Despite the best intentions: a reflection
on low client numbers for a pilot telemedicine sexual health service. J
Fam Plann Reprod Health Care 2013;39:144-146.
2. UNICEF. Young People: Partners for Health. International
Conference Celebrating the 30th Anniversary of Alma Ata Declaration on
Primary Health Care, Final Statement, 16th October 2008.
3. Report of the Children and Young People's Health Outcomes Forum.
2012.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156062/CYP
-report.pdf.pdf [accessed 29 April 2013].
We thank Drs Cogswell and Lipetz[1] for their comments on our
article[2] and for sharing the interesting results of their audits. They
have clearly demonstrated the importance of staff training in increasing
uptake of the emergency intrauterine device (IUD). Further work within our
service supports their conclusion.
In response to the apparent fall in IUD uptake when ulipristil
acetate (UPA) was introduced, the...
We thank Drs Cogswell and Lipetz[1] for their comments on our
article[2] and for sharing the interesting results of their audits. They
have clearly demonstrated the importance of staff training in increasing
uptake of the emergency intrauterine device (IUD). Further work within our
service supports their conclusion.
In response to the apparent fall in IUD uptake when ulipristil
acetate (UPA) was introduced, the results of our study were disseminated
and all staff reminded of the importance of offering an IUD as first line
to all eligible women.
In the 15 months following the data period for our article, 733
patients attended for emergency contraception; 76% received
levonorgestrel, 13% received UPA and IUD uptake was 11% (up from 8.7%
during the study). Although this improvement is modest, within this
interval is a 3-month period during which IUD uptake was significantly
higher at 17.9%. This followed the introduction in October 2012 of a
patient group directive for UPA that was accompanied by a face-to-face
teaching session.
Our initial study, subsequent audit and the findings of Drs Cogswell
and Lipetz all emphasise the importance and impact of continuous staff
education and training. Although staff training is a key element for
inclusion in all service specifications, when there are competing
interests and demands it is often inadequately resourced. This under-investment potentially threatens the projected financial and psychological
savings from increasing use of the emergency IUD and other long-acting
reversible contraceptive methods in general.
References
1. Cogswell C, Lipetz C. Comment on 'An emergency contraception
algorithm based on risk assessment: changes in clinicians' practice and
patients' choices'. J Fam Plann Reprod Health Care 2013;39:1. doi.
10.1136/jfprhc-2013-100663.
2. McKay RJ, Gilbert L. An emergency contraception algorithm based on
risk assessment: changes in clinicians' practice and patients choices. J
Fam Plann Reprod Health Care 2013;39:1-7. doi. 10.1136/jfprhc-2012-100495.
Dr Elliman[1] asked whether other clinicians had experience of
damaged implants. Rekers[2] 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...
Dr Elliman[1] asked whether other clinicians had experience of
damaged implants. Rekers[2] 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 Bacon[3] 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. Doshi[4]
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.
References
1. Elliman A. Removal of a fractured Nexplanon?. J Fam Plann Reprod
Health Care 2013;39:66-67.
2. Rekers K. Removal of a fractured Nexplanon?: MSD response. J Fam
Plann Reprod Health Care 2013;39:67.
3. Pickard S, Bacon L. Persistent vaginal bleeding in a patient with
a broken Implanon?. J Fam Plann Reprod Health Care 2002;28:207-208.
4. Doshi J. Bent Implanon?. J Fam Plann Reprod Health Care
2011;37:126.
The commentary by Horga et al.[1] on the consequences of Ceausescu's attempt to ban abortion in Romania is a stark reminder of what happens when women are prevented from accessing safe and legal means to end problem pregnancies. In short, they end their pregnancies using means that are unlawful and/or unsafe, sometimes with tragic consequences.
Although it is difficult to compare any country today with the repre...
I read with interest Dr MacGregor's letter[1] regarding the unusual shape of a Mirena intrauterine system (IUS) following removal. From the photograph it would appear that the capsule has become displaced and the arms of the device enclosed within it.
We have seen a case of complete detachment of the capsule from the frame, with unrecognised retention of the capsule within the uterine cavity. This was only reco...
I read the article by Briggs and colleagues[1] with interest as it is, to my knowledge, the only study to assess the impact of the implementation of the UK Medical Eligibility Criteria on general practice prescribing of combined hormonal contraceptives (CHCs) in the UK. However, I have a study limitation.
As the authors have stated, oral contraception can be accessed on prescription from a general practitioner (...
I read the letter on 'Early implant removal: an ethical dilemma' by Bari et al.[1] in the January 2013 issue of the Journal with interest, a great feeling of disappointment and I shared the feelings of alarm with the authors. The piece reported a 29-year-old woman who was so dissatisfied with her subdermal implant that she attempted removal herself without anaesthetic and she broke the device. She had requested removal f...
On behalf of all the authors I would like to thank Sarah Holden for her comments[1] on our recently published article.[2]
When designing the study, we recognised that the majority of women receive their contraception from their general practitioner (GP). Our study compares the prescribing habits of GPs in 2005 pre-UK Medical Eligibility Criteria (pre-UKMEC) to those in 2010 (post-UKMEC).
Whilst the aut...
I read with interest Anne MacGregor's letter in the January 2013 issue of the Journal describing the removal of an unusually shaped intrauterine system (IUS) and asking if others have had similar experiences.[1]
A couple of years ago I too was alarmed as I removed an IUS through a slightly tight cervical os and noted an odd shape. On closer inspection the device was removed intact but as in Dr MacGregor's case t...
As with McKay and Gilbert[1] in Cambridge, UK, we also developed an emergency contraception (EC) algorithm following the introduction of ulipristal acetate (UPA), likewise recognising that fitting an intrauterine device (IUD) was the 'gold standard'. Our ongoing experience is rather different, however, in that our rates of emergency IUD fitting have increased since the introduction of our algorithm from 6% to at least 9%...
I read with interest the article Garrett and Kirkman et al.[1] wrote on the limited success of the pilot telemedicine sexual health service and their reflections on needing more advice from what young people thought to have got it right.
A 2008 UNICEF statement entitled 'Young People: Partners for Health'[2] written by an international group of young people states: "Young people need to be at the forefront in the...
We thank Drs Cogswell and Lipetz[1] for their comments on our article[2] and for sharing the interesting results of their audits. They have clearly demonstrated the importance of staff training in increasing uptake of the emergency intrauterine device (IUD). Further work within our service supports their conclusion.
In response to the apparent fall in IUD uptake when ulipristil acetate (UPA) was introduced, the...
Dr Elliman[1] asked whether other clinicians had experience of damaged implants. Rekers[2] 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...
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