Consent for Progestin Implant Insertion at Medical Services

The procedure for insertion of a progestin implant has been explained to me. I am requesting this method of birth control and am aware of the alternative options for contraception. I understand the advantages, effectiveness, risks, actions, and side effects of the progestin implant.  

Possible complications, although unlikely, have been explained to me. These include, but are not limited to, skin infection, scarring of the skin, bruising, and swelling in the arm where it was placed.  

I have been counseled on the following:  

  • No contraceptive, including the progestin implant, is 100% effective in preventing pregnancy.  
  • I can expect temporary pain at the site of insertion and/or skin bruising which will resolve with time. There may be a small scar where the implant is inserted. 
  • While pregnancy with Nexplanon is rare, if I am pregnant, there is an increased risk of an ectopic pregnancy (pregnancy outside the uterus), which can be life-threatening if not treated.   
  • The progestin implant does not protect against sexually transmitted diseases.  
  • I can check for the implant by placing my fingertips over the skin where the implant was placed.  
  • I will contact my healthcare provider if I cannot feel the rod.  
  • The implant is effective for 5 years. I must have it removed after 5 years, although it can be removed sooner if I wish.  
  • Removal is usually a minor procedure. Sometimes, removal may be more difficult. Special procedures, including surgery in the hospital, may be necessary for removal. Difficult removals may cause pain and scarring and may result in injury to nerves and blood vessels. If the implant is not removed; its effects may continue.  
  • Most people have changes in their menstrual bleeding pattern while using the progestin implant, including lighter, heavier or irregular bleeding, or bleeding may stop completely. If I think I am pregnant, I will contact my healthcare provider as soon as possible.  
  • The manufacturer’s patient package insert will be provided during the visit, which explains how Nexplanon works, risks, and potential side effects. 

While insertion is expected, I have been given no guarantee that the procedure will be successful.  

I have been told that the following conditions may preclude the use of the implant:  

  • Current pregnancy.  
  • History of thrombotic disease.  
  • Current or history of ischemic heart disease.  
  • History of cerebrovascular disease.  
  • Unexplained vaginal bleeding.  
  • Systemic Lupus Erythematosus with positive or unknown antiphospholipid antibodies.  
  • Current breast cancer or breast cancer within the last 5 years.  
  • Severe decompensated cirrhosis.  
  • Hepatocellular adenoma or malignant hepatoma.  

In the event of a problem, I am to call Medical Services at 212-854-7426 to make an appointment with a provider. 

Information

View more information on Getting a Contraceptive Implant (Nexplanon®) at Columbia Health.