A novel method of "Pre-fabricated Knot" hysteroscopic levonorgestrel-releasing intrauterine system suture fixation

OBJECTIVE: To introduce a novel hysteroscopic suture fixation technique using a "pre-fabricated knot". This is used for levonorgestrel-releasing intrauterine system placement in adenomyosis treatment. DESIGN: Step-by-step video of "pre-fabricated knot" hysteroscopic levonorgestrel-releasing intrauterine system suture fixation. The study was approved by the Institutional Review Board of the International Peace Maternity and Child Health Hospital. Informed consent was obtained from the patients. SUBJECTS: A 48-year-old nulliparous female diagnosed with adenomyosis suffering from severe dysmenorrhea and menorrhagia for nearly 7 years. The symptoms worsened over the past 6 months. Previous treatments included high-intensity focused ultrasound ablation and ongoing dienogest therapy. Laboratory tests revealed mild anemia, and transvaginal ultrasound showed a globular uterine enlargement equivalent to a 14-week gestation. The patient declined a hysterectomy because of a strong fertility preservation desire. EXPOSURE: Transvaginal ultrasonography was used to assess the uterus volume and the position of the levonorgestrel-releasing intrauterine system before and after treatment. The patient underwent the operation after a 3-month course of mifepristone. After preparatory curettage, the levonorgestrel-releasing intrauterine system was fixed within the uterine cavity using a suture with prefabricated, bead-like knots, thereby achieving the effect of anchoring the device, preventing it from falling off. MAIN OUTCOME MEASURES: Safety and efficiency of this novel technique. RESULTS: The levonorgestrel-releasing intrauterine system was successfully fixed on the posterior uterine wall in 10 minutes with no blood loss. The patient was discharged 2 hours after the operation without complications. At 1-month follow-up, she reported that her dysmenorrhea and menorrhagia had improved. Currently, we have completed 17 surgeries from April to August 2025. To date, no cases of expulsion or complications have been observed. Furthermore, we have observed preliminary positive outcomes in symptom relief. CONCLUSION: The technique offers equal efficacy, reduced operative time, and enhanced safety because of its simplified procedural steps. However, its indication should currently be limited to adenomyosis patients with anemia, dysmenorrhea, and menorrhagia, particularly those with a history of intrauterine device expulsion. Future studies with extended follow-up periods and larger patient cohorts are warranted to further evaluate the long-term outcomes of this technique.