Risk of early etonogestrel and levonorgestrel implant discontinuation in adolescents and adults.

We conducted a retrospective cohort study of women who initiated contraceptive implants at the Family Planning Clinic at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. The Family Planning Clinic in King Chulalongkorn Memorial Hospital offers contraceptive services for the general public and for postpartum individuals who delivered at the hospital. Individuals aged 15–49 years who received etonogestrel implants between January 1st, 2017 and December 31st, 2019, and levonorgestrel implants between January 1st, 2014 and December 31st, 2019 were included. Those who did not have the outcome data (no show at appointment date and were not contactable by phone) in medical records or who did not consent to data usage were excluded. Participants provided written informed consent for data usage in research at registration for hospital services; those who did not give consent were excluded. Demographic data, obstetric history, and contraceptive details including the date of insertion and date of removal were extracted from medical records. The study protocol was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University, and the study was conducted in accordance with the Declaration of Helsinki. This research was funded by the Ratchadapisek Sompot Fund. Individuals who sought contraceptive services were offered counselling on available modern methods of contraception by a trained nurse or a physician. Both levonorgestrel implants (Jadelle®, Bayer Schering Pharma, Turku, Finland) and etonogestrel implants (Implanon NXT®, Merck/MSD, Oss, Netherlands) are available to participants and the choice between them is based on user preference. Those who opted for contraceptive implants were given information on the effectiveness, safety, potential complications, procedure for implant insertion and removal, and side effects, including irregular menstrual bleeding. A trained physician performed the insertion procedure. Individuals were scheduled for follow-up appointments 7 and 90 days after the insertion, and then annually thereafter. Individuals who missed their appointments were followed up via telephone interview. Those who had their implants removed were asked their reason for discontinuation, approximate date of implant removal, and subsequent contraception method after implant removal. Early contraceptive implant removal was defined as the removal of levonorgestrel implants before 4 years 11 months and the removal of etonogestrel implants before 2 years 11 months, as these contraceptive implants are currently approved for 5 and 3 years respectively. Implant removal within 1 month of the due date was not classified as early removal to accommodate for patient scheduling. The definition of early contraceptive implant removal varies across studies, ranging from removal at any time before the approved 3 and 5 years to removal within the first year [ 10 – 15 ]. Previously, we studied the rate of early implant removal within the first year in a separate cohort and reported that it was 2.8 and 4.2 per 100 person-years for adolescents and adults respectively [ 15 ]. Continuous users were individuals who were using either type of implant until completion, had those implants removed and new contraceptive implants inserted in the same visit. Individuals with BMI > 23 kg/m 2 and > 25 kg/m 2 were considered overweight and obese, respectively, as per the cut-off in Asian populations [ 16 ]. Individuals aged 15–19 years were defined as adolescents, and individuals aged 20–49 were defined as adults. Study data were extracted from electronic medical records and managed via REDCap electronic data capture tools hosted at the Faculty of Medicine, Chulalongkorn University [ 17 , 18 ]. During the study period, individuals aged 10–19 years were able to receive their contraceptive implants free of charge under the National Health Security Office (NHSO) policy in Thailand [ 19 ]. Since 2015, these individuals have been able to access contraceptive services without needing parental consent under the Act for Prevention and Solution of the Adolescent Pregnancy problem [ 19 ]. Individuals of all ages who reside in Bangkok may also access contraceptive implants free of charge under the NHSO [ 19 ] act, however, the policy does not extend to non-Bangkok residents who seek medical care in Bangkok. Access to contraceptive implants is facilitated appointments via a mobile application or by in-hospital consultation [ 20 ]. Statistical analysis was conducted via STATA version 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.). Demographic characteristics and obstetric characteristics are summarized as the means with standard deviations, or as numbers and percentages, depending on the type of data. Basic characteristics and clinical factors were compared between adolescents and adults were assessed via Fisher’s exact test. The cumulative incidence of early implant removal for each age group was assessed using Kaplan–Meier survival functions. Cox proportional hazard models were used to identify factors associated with early implant removal. Backwards logistic regression was used to select potential confounders for inclusion in the final model. Multicollinearity of variables was assessed using variance inflation factor (VIF). Statistical significance was set at p  < 0.05.

A total of 1873 individuals met our inclusion criteria, with 438 excluded because of the absence of outcome data in the medical records (not contactable by phone or no-show at appointment date) (Fig.  1 ). Levonorgestrel implants were used by 765 (53.3%) and etonogestrel implants were used by 670 (46.7%). Among these, 409 (28.5%) were adolescents with a mean age of 17 ± 1.30 years, and 1026 (71.5%) were adults with a mean age of 30.2 ± 7.2 years. Almost all adolescents (93.4%) and a third (27.7%) of the adults received their implants free of charge, and most were new users (98.3% adolescents and 83.2% adults). Adults used both types of implants equally, whereas adolescents were more likely to use levonorgestrel implants than etonogestrel implants. More than half (56.2%) of the adolescents started their implants postpartum compared to 34.9% of the adults. Adolescents were more likely to report being single (53.8% in adolescents compared to 25.3% of adults) than married or cohabitating (35.0% compared to 57.5% in adolescents and adults, respectively) (Table  1 ). Fig. 1 Study flow Table 1 Demographic characteristics Adolescents (age 15–19 years) n (%) ( n  = 409) Adults (age 20–49 years) n (%) ( n  = 1026) Study population n (%) ( n  = 1435) Age (years)  15–19 409 (28.5)  20–24 271 (18.9)  25–29 289 (20.1)  30–34 181 (12.6)  35–39 158 (11.0)  40–44 87 (6.1)  45–49 40 (2.8) Payment method  Paid by patient 27 (6.6) 742 (72.3) 769 (53.6)  Free-of-charge 382 (93.4) 284 (27.7) 666 (46.4) Marital status  Married or cohabitating 143 (35.0) 590 (57.5) 733 (51.1)  Single 220 (53.8) 260 (25.3) 480 (33.4)  Divorced 1 (0.2) 6 (0.6) 7 (0.5)  No data 45 (11.0) 170 (16.6) 215 (15.0) Continuous users a  Continuous users 7 (1.7) 172 (16.8) 179 (12.5)  New users 402 (98.3) 853 (83.2) 1255 (87.5) Contraceptive implant type  Levonorgestrel (Jadelle®) 281 (68.7) 484 (47.2) 765 (53.3)  Etonogestrel (Implanon NXT®) 128 (31.3) 542 (52.8) 670 (46.7) Postpartum status b  Non-postpartum 174 (42.5) 640 (62.4) 814 (56.7)  Postpartum 230 (56.2) 358 (34.9) 588 (41.0)  Post-abortion 5 (1.3) 28 (2.7) 33 (2.3) Living children  0 147 (35.9) 288 (28.1) 435 (30.3)  1 225 (55.0) 384 (37.4) 609 (42.4)  2 33 (8.2) 254 (24.8) 287 (20.0) > 2 1 (0.2) 78 (7.6) 79 (5.5)  Unknown 3 (0.7) 22 (2.1) 25 (1.8) Body mass index (BMI) (kg/m 2) < 18.5 37 (16.6) 22 (5.3) 59 (9.1)  18.5- < 23 122 (55) 213 (50.0) 335 (51.7)  23- < 25 15 (6.8) 74 (17.4) 89 (13.7)  25-  40 0 (0.0) 2 (0.5) 2 (0.4) Ethnicity  Thai 409 (100.0) 1008 (98.2) 1417 (98.8)  Others c 0 (0) 18 (1.8) 18 (1.2) a Continuous users were individuals who were using either type of implants until completion, had those implants removed and new contraceptive implants inserted in the same visit b Postpartum signifies 6 weeks since giving birth c Specific data on “others” ethnicity was not collected. Examples of other ethnicities found in our hospital: Laotian, Myanmar, Vietnamese Study flow Demographic characteristics a Continuous users were individuals who were using either type of implants until completion, had those implants removed and new contraceptive implants inserted in the same visit b Postpartum signifies 6 weeks since giving birth c Specific data on “others” ethnicity was not collected. Examples of other ethnicities found in our hospital: Laotian, Myanmar, Vietnamese Approximately 80% of both levonorgestrel and etonogestrel implants were used to completion: 79.7% and 80% for adolescents and adults using levonorgestrel, and 93% and 78.8% for adolescents and adults using etonogestrel implants, respectively. Early implant removal rates for levonorgestrel were 2.1%, 5.3%, 6.8%, 3.9%, 2.1% for the first, second, third, fourth, and fifth year, respectively, and 4.8%, 7.2%, 7.0% in the first through third year for etonogestrel implants (each number represents early removal for that year, excluding preceding years). Levonorgestrel implants were removed early most often in the third year of usage, while etonogestrel implants were removed equally often in the second and third years. Early implant removal rates were comparable between adults and adolescents (Table  2 ). The most commonly cited reason for early implant removal was intolerance of side effects (approximately two-thirds of early implant removal), followed by the desire for pregnancy, and lack of sexual activity. Other reasons include wanting to switch to another method and disliking the feeling of implants. Approximately two-thirds of early implant removal due to intolerance side effects was due to irregular menstrual bleeding, followed by weight change. Other side effects leading to early removal includes breast tenderness, hair loss, leukorrhea, mood changes, dry skin, and acne. In regards to method of contraception used after early implant removal, approximately one-fifth of adolescents and one-third of adults did not use any method of contraception at all, constituting the largest subset of this group. Of individuals who switched to another method of contraception, oral contraceptive pills were the most commonly used, followed by male condoms, injectable contraceptives, male or female sterilization, or intrauterine devices. Table 2 Early implant removal by type Levonorgestrel implant (Jadelle®) Etonogestrel implant (Implanon NXT®) Total Adolescents n (%) ( n  = 281) Adults n (%) ( n  = 484) Total n (%) ( n  = 765) P value b Adolescents n (%) ( n  = 128) Adults n (%) ( n  = 542) Total n (%) ( n  = 670) P value Adolescents ( n  = 409) Adults ( n  = 1026) Total ( n  = 1435) Discontinuation a  Within 1st year 6 (2.1) 16 (3.3) 22 (2.9) 0.350 2 (1.6) 30 (5.5) 32 (4.8) 0.058 8 (2.0) 46 (4.5) 54 (3.8)  Within 2nd year 15 (5.3) 26 (5.3) 41 (8.8) 0.954 2 (1.6) 46 (8.5) 48 (7.2) 0.005 17 (4.2) 72 (7.0) 89 (6.2)  Within 3rd year 19 (6.8) 30 (6.2) 49 (6.4) 0.773 6 (4.7) 38 (7.0) 44 (6.6) 0.409 25 (6.1) 68 (6.6) 93 (6.5)  Within 4th year 11 (3.9) 18 (3.7) 29 (3.8) 0.648 11 (2.7) 18 (1.8) 29 (2.0)  Within 5th year 6 (2.1) 7 (1.4) 13 (1.7) 0.726 6 (1.5) 7 (0.7) 13 (0.1)  Total early discontinuation 57 (20.3) 97 (20.0) 154 (20.1) 10 (7.9) 114 (2.2) 124 (18.5) 67 (16.4) 211 (20.6) 278 (19.4)  Full use of implants 224 (79.7) 387 (80.0) 611 (79.9) 118 (93.0%) 427 (78.8) 545 (81.5) 342 (83.6) 814 (79.3) 1156 (80.6) Reasons for discontinuation  Side effects 34 (59.6) 48 (49.5) 82 (53.2) 0.347 7 (70) 70 (61.4) 77 (62.1) 0.347 41 (61.2) 118 (55.9) 159 (57.2)  Desire for pregnancy 11 (19.3) 27 (27.8) 38 (24.7) 0.307 0 (0) 34 (29.8) 34 (27.4) 0.307 11 (16.4) 61 (28.9) 72 (25.9)  Not sexually active 5 (8.8) 7 (7.2) 12 (7.8) 0.767 1 (10) 2 (1.8) 3 (2.4) 0.767 6 (9) 9 (4.3) 15 (5.4)  Other 10 (17.5) 19 (19.6) 29 (18.8) 3 (30) 15 (13.2) 18 (14.5) 13 (19.4) 34 (16.1) 47 (16.9) Side effects causing discontinuation d  Irregular bleeding 21 (61.8) 29 (60.4) 50 (61.0) 5 (71.4) 42 (60.0) 47 (61.0) 0.424 26 (63.4) 71 (60.2) 97 (61.0)  Weight change 10 (29.4) 9 (18.8) 19 (23.2) 1 (14.3) 24 (34.3) 25 (32.5) 11 (26.8) 33 (28.0) 44 (27.7)  Mood changes 5 (14.7) 3 (6.3) 8 (9.8) 0 (0) 13 (18.6) 13 (16.9) 5 (12.2) 16 (13.6) 21 (13.2)  others 10 (29.4) 24 (50.0) 34 (41.5) 3 (42.9) 32 (45.7) 35 (45.4) 13 (31.7) 56 (47.5) 69 (43.4) Method of contraception after discontinuation c  Oral contraceptive pills 9 (15.8) 23 (23.7) 32 (20.8) 0.302 6 (60) 31 (27.2) 37 (29.8) 15 (22.4) 54 (25.6) 69 (24.8)  Condom 2 (3.5) 12 (12.4) 14 (9.1) 0.079 0 (0) 12 (10.5) 12 (9.7) 2 (3) 24 (11.4) 26 (9.4)  Injectable contraceptives 7 (12.3) 3 (3.1) 10 (6.5) 0.043 0 (0) 4 (3.5) 4 (3.2) 7 (10.4) 7 (3.3) 14 (5.0)  Intrauterine device 0 (0) 1 (1.0) 1 (0.6)  > 0.999 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.5) 1 (0.4)  Sterilization (male and female) 0 (0) 2 (2.1) 2 (1.3)  > 0.999 0 (0) 2 (1.8) 2 (1.6) 0 (0) 4 (1.9) 4 (1.4)  No contraception 14 (24.6) 32 (33) 46 (29.9) 0.361 1 (10.0) 40 (35.1) 41 (33.1) 15 (22.4) 72 (34.1) 87 (31.3)  Other 25 (8.9) 26 (9.3) 51 (18.1) 3 (30.0) 28 (24.6) 31 (25) 28 (41.8) 54 (25.6) 82 (29.5) a Etonogestrel implants are due for removal after 3 years and do not have early removal data for the 4th and 5 years b p -value < 0.05 is considered statistically significant and calculated from Fisher’s exact test. P -values are included for clinically relevant factors c Participants could select more than one option; percentages calculated from individuals who had early removal of implants d Participants could select more than one option; percentages calculated from individuals who indicated side effects as the primary reason for early removal Early implant removal by type a Etonogestrel implants are due for removal after 3 years and do not have early removal data for the 4th and 5 years b p -value < 0.05 is considered statistically significant and calculated from Fisher’s exact test. P -values are included for clinically relevant factors c Participants could select more than one option; percentages calculated from individuals who had early removal of implants d Participants could select more than one option; percentages calculated from individuals who indicated side effects as the primary reason for early removal Univariable Cox-proportional hazard analysis revealed that early contraceptive implant discontinuation was statistically significantly less likely in adolescents compared with adults (HR = 0.72, 95% CI = 0.55–0.90). This association remained significant after adjusting for potential confounders in the multivariable analysis (adjusted HR = 0.70, 95% CI = 0.51–0.97), as shown in Table  3 . Factors that were significantly associated with early removal in the multivariable model were being single or divorced (adjusted HR = 1.33, 95% CI = 1.001, 1.76 and adjusted HR = 1.18, 95% CI = 0.16–8.44, respectively) and being a continuous user (adjusted HR 0.50, 95% CI 0.30–0.82), The survival curve for early implant removal, categorized by type of contraceptive implant, is displayed in Fig.  2 . Table 3 Cox-proportional hazard analysis for early implant removal Crude HR (95% CI) p -value Adjusted HR a (95% CI) p -value Age group  Adolescents (15–19 years) 0.72 (0.55, 0.95) 0.019 0.70 (0.51, 0.97) 0.030  Adults (20–49 years) Reference Reference Reference Ethnicity  Thai 0.42 (0.20, 0.89) 0.022 0.46 (0.20, 1.04) 0.06  Other c Reference Reference Reference Reference Payment method  Free of charge 0.75 (0.58, 0.95) 0.018  Paid by patient Reference Reference Marital status b  Married or cohabitating Reference Reference Reference Reference  Single 1.22 (0.93, 1.60) 0.159 1.33 (1.00, 1.76) 0.049  Divorced 0.97 (0.14, 6.95) 0.976 1.18 (0.16, 8.44) 0.873 Body mass index (BMI) < 18.5 0.57 (0.26, 1.24) 0.153  18.5- < 23 Reference Reference  23-  = 25 0.91 (0.60, 1.40) 0.671 Continuous users  Yes 0.56 (0.36, 0.86) 0.009 0.50 (0.30, 0.82) 0.006  No Reference Reference Reference Reference Contraceptive implant type  Levonorgestrel (Jadelle®) 0.79 (0.61, 1.02) 0.068  Etonogestrel (Implanon NXT®) Reference Reference Postpartum group  Non-postpartum Reference Reference  Postpartum 0.77 (0.60, 0.98) 0.036  Postabortion 0.94 (0.44, 2.00) 0.870 Number of living children  No living children Reference Reference  One or more living child 0.77 (0.60, 0.99) 0.043 a Adjusted by age group, ethnicity, marital status, and continuous user status b Hazard ratio excludes those with missing data for 215 individuals c Specific data on “others” ethnicity was not collected. Examples of other ethnicities found in our hospital: Laotian, Myanmar, Vietnamese Fig. 2 Kaplan Meier curve for early implant removal by type of contraceptive implant Cox-proportional hazard analysis for early implant removal a Adjusted by age group, ethnicity, marital status, and continuous user status b Hazard ratio excludes those with missing data for 215 individuals c Specific data on “others” ethnicity was not collected. Examples of other ethnicities found in our hospital: Laotian, Myanmar, Vietnamese Kaplan Meier curve for early implant removal by type of contraceptive implant

Unintended pregnancy is a global problem with a significant burden on the healthcare system. Children resulting from unintended pregnancies are more likely to drop out of school, exhibit delinquent behavior, have mental health problems, and negatively impact a nation’s economic performance and growth at the macro level [ 1 ]. Contraceptive implants are 99.9% effective in preventing unintended pregnancy and require minimal user compliance after the initial insertion visit [ 2 ]. Thailand has introduced a succession of changes in contraceptive provision to reduce unintended pregnancies. Currently, adolescents are able to access contraceptive implants completely free of charge, and those aged 10 years and above are able to receive contraceptive services without needing parental consent [ 3 ]. Since 2014 and 2016, when these changes were implemented, adolescent pregnancy rates in Thailand have decreased from 60 per thousand women in 2012 [ 4 ] to 18 per thousand women in 2022 [ 5 ]. Early contraceptive implant removal is the discontinuation of contraceptive implants before their completion-3 years for etonogestrel implants and 5 years for levonorgestrel implants. Contraceptive implants wear off rapidly after removal, resulting in return to fertility. The pregnancy rate after implant removal was 20% at one month and 80% after one year [ 6 ]. High rates of early implant removal contribute to reduced efficacy and a greater risk of unintended pregnancy [ 7 ]. Reducing early implant removal from modifiable causes will also lead to more effective utilization of contraceptive funding. Previous studies at our hospital revealed that 3.8% of individuals discontinued their implants within the first year. Discontinuation rates vary in other areas: a systematic review reported discontinuation rates of 10–23% [ 8 ], while a study in Northeastern Thailand reported a discontinuation rate of 8.7–8.9% [ 9 ]. We aimed to estimate the rates of early implant removal for both levonorgestrel and etonogestrel implants and to determine the demographic and clinical factors associated with early implant removal.

In conclusion, contraceptive implant discontinuation for both the levonorgestrel and etonogestrel implants were lower in adolescents when compared to adults. Continuous users, those who receive free implants, postpartum insertion, individuals with one or more living children were less likely to remove their implants prematurely.

Early contraceptive implant removal contributes to reduced contraceptive efficacy and a greater risk of unintended pregnancy. We conducted a retrospective cohort study to determine early implant removal rates for etonogestrel and levonorgestrel implants in adolescents and adults and to identify factors associated with early contraceptive implants. Our study revealed that adolescents were less likely to remove contraceptive implants early compared to adults. Early implant removal rates were 20.3% for levonorgestrel implants and 18.5% for etonogestrel implants, and approximately 2–4% removed implants within the first year. Early removal rate was similar across the first to third or first to fifth year for etonogestrel and levonorgestrel implants, respectively. Continuous implant users, those who were single or divorced, and individuals receiving implants free-of-charge were less likely to have early implant removal. Approximately a third of individuals did not initiate another method of contraception after implant removal. Early implant removal rates were relatively low compared with those reported in other studies. A systematic review [ 8 ] reported removal rates ranging from 23–42%. Other studies in Uganda, Kenya, and Ethiopia reported early implant discontinuation rates between 31 and 56% [ 10 , 11 , 14 ]. The Contraceptive CHOICE project [ 21 ] in the USA reported that that 17% removed their implants in the first year. In a study assessing efficacy and safety of etonogestrel implants, Croxatto et al. [ 22 ] found that the discontinuation rate was 31% in the first year. A study in another region of Thailand found the first year implant removal rate was 8.9% [ 9 ]. Our hospital is a tertiary care center and includes individuals who receive implants for gynecologic conditions such as dysmenorrhea, endometriosis, those unable to perform menstrual care, and individuals with medical conditions that strongly preclude pregnancy. These individuals may be more strongly motivated to retain implants than the general population due to non-contraceptive benefits. A previous study conducted at our hospital found that early implant removal rate was similarly low at 3.8%, and early removal was not significantly different in adolescents and adults [ 15 ]; however only early implant removal for the first year after insertion was recorded in that study. The most commonly stated reason for early implant removal was intolerance of side effects, with approximately two-thirds were due to irregular menstrual bleeding. This is in accordance with other studies where irregular bleeding was found to cause embarrassment, a sense of loss of bodily control, and affected their sexual experiences [ 23 ]. Individuals receiving implants at our hospital undergo multiple rounds of counseling by trained nurses and physicians including education on the occurrence and management of side effects which may account for the lower rate of removal. Almost half of our cohort were postpartum individuals, which may increase tolerability of side effects, as postpartum implant insertion has a lower rate of irregular menstrual bleeding [ 8 , 24 ]. Our study found that adolescent contraceptive implant users were significantly less likely to remove contraceptive implants early when compared to adults, which contrasts with the global trend. Previous studies have shown that adolescents are more likely to than older women to discontinue any contraceptive method, and in most countries a greater proportion of adolescents than adults discontinue any method use while still in need of contraception [ 25 ]. A large cohort study in 2013 found that 33% and 22% of adolescents and adults respectively remove their implants before completion [ 26 ]. Saloranta et al. compared women aged 15–19 years and 20–29 years to 30–44 years [ 27 ] and found a higher incidence of early implant removal in younger women. We believe our findings result from the following: 1. Comprehensive, thorough counselling before and after contraceptive implant initiation, 2. Readily available assistance if discomfort or side effects were experienced after initiation as the hospital service is designed as such, and because our hospital is situated in an area easily accessible by public transport and 3. A large proportion of adolescents in our study initiated contraceptive implants in the postpartum period where repeat pregnancy acts as a deterrent to early discontinuation. Factors associated with lower risk of early implant removal were continuous implant users, married individuals, and individuals receiving implants free-of-charge. Women who have previously had contraceptive implants may be better prepared for side effects, or may fewer side effects than their peers and can better tolerate the next implant. Our study also found that individuals receiving their implants free-of-charge are less likely to remove their implants early. Despite proven benefits of effective contraception in adolescents for both the individual and the community [ 28 ], there is a prevailing perception that adolescents more readily discontinue contraception, which has been argued in opposition to government support for free-of-charge contraceptive implants. Our findings contradict this perception as adolescents were significantly less likely to discontinue implants even after controlling for continuous users and payment type in the multivariate model. Our findings also support ongoing government funding for free contraceptive for implants both for prevention of teenage pregnancy and unwanted pregnancy. The local rate of early implant removal is relatively low compared to other studies, suggesting a higher cost–benefit ratio for implants in preventing unwanted pregnancies in Thailand. Further studies into cost-effectiveness of contraceptive implants will allow for better understanding of the effects of early contraceptive implant removal. Almost a third of adults and a fifth of adolescents in our cohort did not use any contraception after early implant removal. This disparity may be explained by the greater number of adults who discontinue implants due to desire to conceive, reflecting their reproductive autonomy. Supporting reproductive autonomy is critical in the implementation of LARC programs, balancing the prevention of unwanted pregnancy and allowing individuals the right to become pregnant [ 29 ]. As fertility rapidly returns after implant removal, counseling after contraceptive implant removal is vital to ensure that unwanted pregnancy does not occur [ 6 ]. Previous studies [ 21 , 27 , 30 ] reported similar findings that while irregular bleeding is the most commonly cited reason, desire for conception is a significant motivator of early contraceptive implant removal. The study’s strength was in its large population of adults and adolescents which allows for comparison between age groups. Our hospital is also located in an area where contraceptive implants were free for adults as well during the study period, which allows us to study the effects of reimbursement on early implant removal. We also collected early implant removal data from initiation to completion by year allowing for more detailed data interpretation. We were limited by the retrospective nature of the study, as well as lack of data on the level of concern individuals have of side effects, their sexual activity, or bleeding pattern. Further studies should explore cost effectiveness of contraceptive implants individual perception on side effects, the cost-effectiveness of early implant removal, and predictors of individuals who will have troublesome bleeding patterns.

Supplementary Material 1. Supplementary Material 1.