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NORPLANT® Implants


Q.2. When can NORPLANT® Implants be inserted postpartum?

Recommendations

Rationales
For Breastfeeding Women:  
a) If the woman chooses to rely on the Lactational Amenorrhea Method (LAM), insert NORPLANT® Implants when her menses* return, or when the woman is no longer fully or nearly fully breastfeeding or at 6 months postpartum, whichever comes first (see "Relying on Lactational Amenorrhea Method").

* NOTE: In breastfeeding women, bleeding in the first 56 days (8 weeks) postpartum is NOT considered "menstrual" bleeding, because it is not preceded by ovulation.

 a) Risk of pregnancy during lactational amenorrhea is very low: less than 2% in first 6 months postpartum if fully breastfeeding; less than or equal to 7% in first 12 months. If the fully or nearly-fully breastfeeding woman remains amenorrheic, her risk of pregnancy is about the same as her risk with other modern contraceptive methods.
  1. Bellagio Consensus Conference on Lactational Infertility. Bellagio consensus statement on the use of breastfeeding as a family planning method. Contraception 1989;39(5):477-496.
  2. Kennedy KI, Visness CM. Contraceptive efficacy of lactational amenorrhea. The Lancet 1992;339:227-230.
  3. Perez A, Labbok MH, Queenan JT. Clinical study of The lactational amenorrhea method for family planning. The Lancet 1992;339:968-970.
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b) If the woman is fully breastfeeding, but does not want to rely on LAM, ideally wait until at least 6 weeks postpartum to initiate NORPLANT® Implants. If she is only partially breastfeeding and does not want to rely on LAM, it is still advisable to wait at least until 6 weeks postpartum before initiating NORPLANT® Implants. b) Based on animal studies and observed fluctuations of human sex hormones in the first 6 weeks of life, plus the immaturity of the neonatal liver for the metabolism of exogenous steroids, it is considered prudent to wait to initiate progestin-only contraceptives until a breastfeeding woman is at least 6 weeks postpartum.
  1. Harlap S. Exposure to contraceptive hormones through breast milk - Are there long-term health consequences? International Journal of Gynaecology and Obstetrics 1987;25(Suppl):47-55.
  2. Ward RM. Pharmacologic principles and practicalities, in Taeusch HW, Ballard RA, Avery ME (eds). Diseases of the Newborn. Philadelphia, WB Saunders Company, 1991.
    3.

Most studies1-5 have not detected clinically measurable effects on the health or growth of breastfed babies of women who begin using NORPLANT® Implants after 6 weeks postpartum, although not all studies report consistent findings6,7. Based on current literature including studies with other progestin-only methods2,3,8,11, it is unlikely that there is a significant effect on growth of breastfeeding infants whose mothers initiate NORPLANT® Implants after the sixth postpartum week.

 
  1. Affandi B, Karmadibrata S, Prihartono J, Lubis F, Samil RS. Effect of NORPLANT® on mothers and infants in the postpartum period. Advances in Contraception 1986;2:371-380.
  2. WHO Task Force on Oral Contraceptives. Effects of hormonal contraceptives on milk volume and infant growth. Contraception 1984;30(6):505-521.
  3. WHO Task Force on Oral Contraceptives. Special Programme of Research, Development, and Research Training in Human Reproduction. Effects of hormonal contraceptives on breast milk composition and infant growth. Studies in Family Planning 1988;19(6):361-369.
  4. Diaz S, Peralta O, Juez G, Herreros C, Casado M, Salvatierra A, Miranda P, Croxatto H. Fertility regulation in nursing women. VI. Contraceptive effectiveness of a subdermal progesterone implant. Contraception 1984;30(4):311-325.
  5. Shaaban MM. Contraception with progestogens and progesterone during lactation. Journal of Steroid Biochemistry and Molecular Biology 1991;40:705-710.
  6. Diaz S, Herreros C, Juez G, Casado ME, Salvatierra AM, Miranda P, Peralta O, Croxatto HB. Fertility regulation in nursing women: VII. Influence of NORPLANT® Levonorgestrel implants upon lactation and infant growth. Contraception 1985;32(1):53-74.
  7. Shaaban M, Salem H, Abdullah K. Influence of Levonorgestrel contraceptive implants, Norplant, initiated early postpartum upon lactation and infant growth. Contraception 1985;32(6):623-635.
  8. Karim M, Ammar R, El Mahgoub S, El Ganzoury B, Fikri F, Abdou I. Injected progestogen and lactation. British Medical Journal 1971;1:200-203.
  9. Pardthaisong T, Yenchit C, Gray R. The long-term growth and development of children exposed to Depo-Provera during pregnancy or lactation. Contraception 1992; 45:313-324.
  10. Zacharias S, Aguilera E, Assenzo JR, Zanartu J. Effects of hormonal and non-hormonal contraceptives on lactation and incidence of pregnancy. Contraception 1986;33(3):203-213.
  11. McCann MF, Moggia AV, Higgins JE, Potts M, Beeker C. The effects of a progestin-only oral contraceptive (Levonorgestrel 0.03 mg) on breastfeeding. Contraception 1989;40(6):635-648.
   
c) Programs that wish to give clients the option of NORPLANT® Implant insertion immediately postpartum should also give clients the option of returning after 6 weeks to receive NORPLANT® Implants. c) In some service delivery settings, access to NORPLANT® Implants insertion may be difficult for clients to obtain outside of immediate postpartum services.
For Non-Breastfeeding Women:  
a) NORPLANT® Implants can be inserted immediately postpartum and whenever you can be reasonably sure the woman is not pregnant. a) While there may be a theoretical concern of increased thrombogenic effect with combined oral contraceptive use in the first week postpartum, there is no known clinical thrombogenic effect of progestin-only contraceptives; therefore NORPLANT® Implants can be safely inserted immediately postpartum, for non-breastfeeding women.
  1. Injectable Contraceptives: Their Role in Family Planning Care. Geneva, World Health Organization, 1990.
  2. Fotherby K. The progestin-only pill and thrombosis. The British Journal of Family Planning 1989;15:83-85.
  3. Chi I. The safety and efficacy of progestin-only oral contraceptives - An epidemiological perspective. Contraception 1993;47:1-21.
    4.

Any part of Recommendations for Updating Selected Practices in Contraceptive Use may be reproduced or adapted to meet local needs without prior permission from the TG/CWG Secretariat, provided the TG/CWG is acknowledged and the material is made available free of charge or at cost.

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