Two cases of pregnancy during the fourth year of 68 mg etonogestrel implant use

The United States Food and Drug Administration recently expanded approval of the 68 mg radiopaque etonogestrel (ENG) contraceptive implant (Nexplanon, Organon, Oss, The Netherlands) from three years to five years, based on clinical trial data showing no pregnancies in years four or five of use. We present two cases of pregnancy in year four of implant use.

Two patients presented to our medical center's emergency department with ENG implants in situ and were found to have positive pregnancy tests. The first patient had her implant placed three years and one month prior to presentation, and had an intrauterine pregnancy. The second patient had her implant placed three years and five months prior to presentation, and had a tubal ectopic pregnancy.

The first patient underwent a medical termination of pregnancy and implant removal and replacement three days after initial presentation. Her original implant was removed intact. The second patient underwent a laparoscopic right salpingectomy and implant removal and replacement one day after initial presentation. Her original implant was removed intact.

These cases suggest that both intrauterine and ectopic pregnancies can occur in year four of ENG implant use. Further work should be conducted to determine risk factors for implant failure, especially in years four and five of use.