Ulnar Nerve Ligation after Removal of Norplant: A Case Report

Abstract

Levonorgestrel implants are an acceptable and effective long-term option for reversible contraception [6, 11]. These synthetic, biologically active progestogen products have been available since 1975 [7] and have undergone many formulation changes. The Norplant system consists of six 2.4 × 34 mm silicone tubes [6], while newer preparations, such as Implanon, contain only a single rigid capsule [20, 23] and are preloaded for ease of insertion [21]. Norplant has since been discontinued and replaced, however, because of the unavailability of one of its components [36]. As suggested by the manufacturer, Wyeth-Ayerst Laboratories, [6, 30, 44], Norplant capsules are placed subdermally along the medial aspect of the nondominant arm. Through a 2-mm incision, the implants are distributed in a fanlike pattern 6–10 cm proximal to the elbow. Often, the procedure takes less than 10–15 min [44]. The removal procedure generally takes twice as long [21] and involves a 4-mm incision made at the apex of the insertion site, using forceps for extraction of the capsule(s) [30, 44]. While there is evidence of the efficacy and safety of implantable contraceptives [6, 44], both insertion and removal procedures for these implants have been associated with complications. Insertion site complications were noted in 5.9 % of women within the first year of use [15]. Removal complications were reported in 4.5 % of women, most commonly from implant breakage or embedment in the subdermal plane [10]. Further, 48 % of women experienced significant pain during implant removal [12]. We describe a case of significant neuropathy after ulnar nerve ligation during the removal of a Norplant implantable contraceptive.