Introduction Subcutaneous contraceptive implants are reversible oestrogen-free devices designed for long-term pregnancy prevention.

Material and methods A structured search using MeSH vocabulary and title/abstract was conducted in PubMed up to October 2012. Patients’ clinical records were reviewed.

Findings Our case is a woman who had a two-rod contraceptive implant inserted. She had pain at the insertion site, unpredictable vaginal bleeding, abdominal discomfort and eventually amenorrhoea that required medical attention on two occasions and implant removal at her request. However, only one rod was removed as the second was not visible by x-ray or ultrasound. A hypothalamic–pituitary–ovarian axis test was normal, thus the remaining rod was considered non-functional. The patient then experienced hypermenorrhea with anemisation and other side effects such as severe loss of weight and inability to conceive.

Discussion Our patient seems to represent a case of incorrect use of medication, most likely due to incorrect insertion. The invisible rod might be the reason for some of the side effects experienced by our patient, thus extra attention should be paid to this process.