Clinical application of a simplified hysteroscopic LNG-IUD non-suture fixation in the treatment of adenomyosis

Clinical application of a simplified hysteroscopic LNG-IUD non-suture fixation in the treatment of adenomyosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical application of a simplified hysteroscopic LNG-IUD non-suture fixation in the treatment of adenomyosis Yi Yu, Qing Cong, Long Sui, Hongwei Zhang, Limei Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5419588/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Placement of a levonorgestrel-releasing intrauterine device (LNG-IUD) is an effective treatment forpatients diagnosed with adenomyosis who had a strong desire to preserve the uterus and had no immediate fertility requirements. However, there are also some limitations to the suitability of the LNG-IUD for women with adenomyosis, as adenomyosis causes distortion or enlargement of the uterine cavity. Therefore, the LNG-IUD is more prone to expulsion in patients with adenomyosis. In this study, we aimed to show an original and simplified approach using the hysteroscope for non-suture fixation of LNG-IUD in patients with adenomyosis. Methods In this retrospectivecase series approved by the Ethics Committee of Obstetrics and Gynecology Hospital of Fudan University, sixty-two patients diagnosed with adenomyosis who had a strong desire to preserve the uterus and had no immediate fertility requirements in the short term were included in the study. They underwent hysteroscopic non-suture fixation of LNG-IUD. All patients underwent one-year postoperative follow-up to evaluate the LNG-IUD expulsion rate, postoperative efficacy and side effects. Results Sixty-two patients with adenomyosis underwent non-suture fixation with LNG-IUD and during the long-term postoperative follow-up, every patient experienced complete remission of their symptoms: a significant decrease in menstrual flow, relief of dysmenorrhea, and improvement in quality of life. Only two patients experienced expulsion of the LNG-IUD at 6 months and 10 months postoperatively, respectively. Conclusions Hysteroscopic non-suture fixation of the LNG-IUD can be a more simplified and minimally invasive alternative treatment for patients with a history of LNG-IUD expulsion. The non-suture method greatly reduces the complexity of hysteroscopic fixation and can be performed more efficiently in office. Levonorgestrel-releasing intrauterine device adenomyosis hysteroscopy fixation non-suture Figures Figure 1 Figure 2 Figure 3 Background Adenomyosis refers to invasion of endometrial glands and/or stroma into the myometrium and is a heterogeneous gynecologic disease with a range of clinical symptoms, the most common being menorrhagia, prolonged menstruation and progressive dysmenorrhea[ 1 – 3 ]. At present, total hysterectomy is considered to be the most effective treatment for adenomyosis. However, given that many patients have a strong desire to preserve the uterus, the treatment of adenomyosis should be personalized according to patient symptoms, age, and fertility requirements. Currently, medical therapy including contraceptives, danazol, LNG-IUD and gonadotropin-releasing hormone agonists (GnRHa) shows increasing efficacy in patients requiring control of symptoms or fertility treatments[ 4 , 5 ]. Among these, the LNG-IUD is the most promising medical therapy[ 6 , 7 ]. This long-acting hormone-releasing uterine device releases high concentrations of progesterone locally, which can inhibit endometrial proliferation and promote apoptosis of endometrial cells[ 8 , 9 ]. Studies have demonstrated that the LNG-IUD is an effective treatment option for adenomyosis, providing significant relief of dysmenorrhea and reducing menstrual volume while enabling women to maintain fertility[ 10 , 11 ]. However, there are also some limitations to the suitability of the LNG-IUD for women with adenomyosis, as adenomyosis causes distortion or enlargement of the uterine cavity. Therefore, the LNG-IUD is more prone to expulsion in patients with adenomyosis[ 12 – 14 ]. As Park reported, 37.5% of patients with large symptomatic adenomyosis and enlarged uteri experienced expulsion of the LNG-IUD, almost all cases occurring in the first 6 months postoperatively[ 15 ]. To address this problem, this study presents an original and simplified approach using the hysteroscope for non-suture fixation of the LNG-IUD in the uterine of patients with adenomyosis who had a strong desire to preserve the uterus and had no immediate fertility requirements. Methods Patients The study was approved by the Ethics Committee of Fudan University Obstetrics and Gynecology Hospital (approval number: 2022-52). Sixty-two patients with adenomyosis have providing informed consent and been successfully enrolled thus far. Data from patients with adenomyosis, who underwent non-suture fixation of the LNG-IUD at Obstetrics and Gynecology Hospital of Fudan University between October 2022 and July 2023, were collected from October 2022 to July 2024. Data analysis was performed in July 2024. Patients diagnosed with adenomyosis who expressed a strong desire to preserve their uterus and had no immediate fertility requirements were included in the study. Patients with a history of malignant tumor or GnRHa therapy in the preceding 6 months were excluded. Materials The materials used in this study included the following: the levonorgestrel-releasing intrauterine system (Mirena Manufacturer: Bayer; Standard Chinese Medicine: J20090144. 52 mg; 20 µg/24 h), hysteroscopic surgery system (Hangzhou Sode Medical Equipment Co., Ltd.), endoscopic scissors, endoscopic needle holder (Shenyang, Shenda Medical Equipment Co., Ltd.). Operative procedures Under general anesthesia, with the patient positioned in the lithotomy position, hysteroscopy was performed using the HCSS. The key steps of the procedure were summarized as follows. First, the uterine cavity was examined by hysteroscope. If polyps, intrauterine adhesions, endometrial thickening or other abnormalities were discovered, they were treated first to create a suitable fixation environment. Second, the two-tail filaments were surgically knotted several times to form a single knot with the diameter of 2-3mm and the remaining tail filaments were cut off. Meanwhile, bilateral arms of the LNG-IUS were cut off to reduce its weight and resistance in the uterine cavity. Third, endoscopic scissors were inserted into the uterine fundus to form a cavity with a depth of 3-4mm and a width of 1mm. Fourth, the head of the single knot of the LNG-IUD tail filaments was inserted into the myometrium of the uterine fundus by endoscopic scissors and the LNG-IUD was fixed successfully by hysteroscopy without suture. Measurements The primary outcome of interest was the expulsion rate of the LNG-IUD. Secondary outcomes included menstrual volume, dysmenorrhea, the level of hemoglobin, and incidence of adverse reactions, such as irregular bleeding, weight gain, and increased secretions. Blood loss was assessed using the Pictorial Blood Loss Assessment Chart (PBAC), a total score of 100 or more was considered to be menorrhagia[ 16 ]. The degree of dysmenorrhea was evaluated using Visual Analog Scale (VAS). The pain scale was assessed as follows: no pain (0 points), mild pain (1–3 points), moderate pain (4–6 points), and severe pain (7–10 points)[ 17 ]. Postoperative follow-up The status of the LNG-IUD was evaluated by ultrasound and hysteroscopy. Menstrual flow was quantified with a pictorial blood assessment chart (PBAC), and the degree of dysmenorrhea was evaluated on a 100 mm visual analog scale (VAS). Both PBAC and VAS scores were recorded before and 1, 3, 6 and 12 months after insertion of the LNG-IUD. Adverse reactions to the LNG-IUD were recorded in the medical records, including menstrual pattern changes, abdominal discomfort, abnormal vaginal discharge, and climacteric symptoms. Statistical analysis Continuous variables were assessed for normality using the Kolmogorov-Smirnov test, and parametric data were analyzed using the t- test. Data are expressed as mean ± standard deviation (SD), n (%), or median (range). Differences with p<0.05 were considered to be statistically significant. All data were analyzed using SPSS 20. Results The hysteroscopic non-suture fixation of LNG-IUD was operated and the procedures were summarized in Fig. 1 . Ultrasound demonstrated the position of the LNG-IUD was normal at 1, 3, 6 and 12 months after surgery. Hysteroscopy was performed 6 months after surgery, as shown in Fig. 2 . During the study period, sixty-two patients underwent non-suture fixation of the LNG-IUD. Although all procedures were successful, three patients were lost to follow-up. The procedure lasted for 10–15 min. All patients had benign postoperative pathology reports. No intraoperative complications, such as uterine perforation, cervical laceration, water poisoning, or allergies, occurred in any patient. Preoperative clinical data are presented in Table 1 . A total of 59 patients with adenomyosis were included in this study: 41 (69.5%) experienced symptoms of dysmenorrhea, 45 (76.3%) experienced excessive menstrual flow, and 29 (49.2%) had a history of expulsion or removal. Table 1 Properative Clinical Data Age(y)[median(range)] 39(28–51) Symptoms[n(%)] Excessive menstrual flow 41(69.5) Dysmenorrhea 45(76.3) Mild pain 6(10.1) Moderate pain 9(15.3) Severe pain 30(50.8) History of expulsion or removal[n(%)] No 30(50.8) Yes 29(49.1) Hemoglobin(g/L)[mean ± SD] 92.3 ± 13.4 VAS scores[mean ± SD] 6.2 ± 2.4 PBAC scores[mean ± SD] 519.3 ± 280.7 After non-suture fixation of the LNG-IUD, when patients come for follow-up, we inquire about remission of symptoms and monitor the position of the LNG-IUD through ultrasound. The three pictures below clearly illustrate the changes. As observed in all investigated time windows, the mean(± SD) preoperative hemoglobin level was 92.3 ± 13.4g/L, which increased significantly after the no-suture fixation of the LNG-IUD (p < 0.001) (Fig. 3 A). The VAS scores (Fig. 3 B) and the PBAC scores (Fig. 3 C) began to decrease in the first month after LNG-IUD fixation. The downward trend indicated by the broken line in the figures clearly demonstrated that in the one-year from the operation to follow-up, menstrual volume was significantly reduced, dysmenorrhea and quality of life after surgery were notably improved. During the follow-up period, two patients (3.2%) experienced expulsion of the LNG-IUD at 8 and 12 months postoperatively. None of the patients underwent LNG-IUD removal. The most common side effect was irregular bleeding, which occurred in 44.3% of cases. Discussion Adenomyosis is a common gynecological disorder characterized by the invasion of endometrial glands and stroma into the myometrium, which results clinically in abnormal uterine bleeding, pelvic pain, and infertility[ 18 , 19 ]. As the disease adversely affects the quality of life in terms of menstrual symptoms, fertility, and pregnancy outcomes, long-term and effective treatments for adenomyosis are necessary. Some scholars have proposed that adenomyosis may be associated with an increased risk of endometrial cancer since they share several altered molecular pathways and are both associated with similar local microenvironments[ 20 – 22 ]. Therefore, there is an urgent need for long-term and effective treatments for adenomyosis. Relevant studies have shown that the levonorgestrel-releasing intrauterine device can effectively treat the symptoms of abnormal uterine bleeding and dysmenorrhea in the long-term management of adenomyosis[ 23 ]. This is the theoretical basis for our research: the LNG-IUD is indeed a practical option for women requiring fertility-sparing management of adenomyosis. However, high rates of LNG-IUD expulsion may deter patients from continuing treatment of adenomyosis, particularly those with a large uterus volume (> 150 mL)[ 24 ]. A prospective longitudinal study over a 60-month follow-up period (the longest follow-up of LNG-IUS for the treatment of adenomyosis to date) reported that the expulsion rate reached up to 21.8% when the patient had undergone pretreatment with GnRHa[ 25 ]. Approximately one-third of the patients had the LNG-IUD replaced, while more than half opted for alternative therapies, resulting in a waste of health care resources and increased anxiety among patients[ 26 , 27 ]. Some studies have confirmed that pretreatment with gonadotropin-releasing hormone analog (GnRHa) is beneficial in reducing the size of uterus and it does greatly reduce the incidence of LNG-IUD expulsion[ 28 , 29 ]. On the other hand, the adverse effects of GnRHa (e.g., menopausal symptoms and risk of osteoporosis) and the cost-benefit profile should be carefully considered. In contrast, our approach offers greater advantages due to fewer side effects and lower costs. To keep LNG-IUD from sliding off, several clinicians attempt to fix it in the uterus. To prevent separation, gynecologists stitch LNG-IUD into the uterine cavity. Zhu et al. first reported the fixation of LNG-IUD under hysteroscopy[ 30 ]. Paul G et al. demonstrated two methods for fixation of LNG-IUD under hysteroscopy[ 31 ]. In this study, we fixed the LNG-IUD under hysteroscopy without suture. To date, we have completed more than sixty cases of non-suture fixation of the LNG-IUD using this improved approach. The patient group is being followed up, with the follow-up period of 12 months, and only two cases of expulsion have occurred. Thus, we improved the procedure further, and we replaced the LNG-IUD tail thread that was fixed at the base of the uterus with a non absorbable surgical sutures (ETHI-CON). So far, no additional discharge of the LNG-IUD has occurred. This improved approach involves a better method of knotting in vitro and simplifies the process of LNG-IUD fixation without usage of endoscopic needle holder or endoscopic scissors. On the one hand, the operation time is greatly shortened; on the other hand, the method of knotting outside the body avoids repeatedly entering and leaving the uterus, thereby lowering the risk of intrauterine infection. In addition, this improved approach greatly reduces the difficulty of the operation, making it easier for clinicians to get started. With the improvements made by our team, the operation is simplified and easy to implement on a large scale, while remaining cost-effective. Hysteroscopic non-suture fixation of LNG‑IUD is an efficient technique that has achieved effective LNG‑IUD fixation in the uterine cavity, with the advantages of being easy to operate, having a short learning curve, requiring no special equipment or instruments not even the use of an endoscopic needle holder or endoscopic scissors, causing minimal surgical trauma, having a short operation time, allowing for quick recovery and easy removal. Therefore, this procedure is suitable to be performed in hospitals at all levels. Conclusions Hysteroscopic non-suture fixation of the LNG-IUD can be a simplified and minimally invasive alternative treatment for patients with adenomyosis who have a history of LNG-IUD expulsion. The non-suture method greatly reduces the hysteroscopic difficulty of fixation and can be performed more efficiently in office. Declarations Conflict of Interest The authors declare that they have no conflicts of interest. Availability of Data and Materials The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors. Authors’ Contributions Limei Chen and Hongwei Zhang designed the study, Yi Yu, Qing Cong, Long Sui collected the data; Yi Yu and Qing Cong analyzed the data and wrote the manuscript. All authors read and approved the final manuscript. Funding The costs of the study were covered by the authors, and no funding was received from any institution or organization. Ethics Approval Ethics committee approval was granted by the Institutional Review Board of the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China. Informed Consent An informed consent form was obtained from the patients before their participation in the study. References Kho KA, Chen JS, Halvorson LM. 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The suture fixation of levonorgestrel-releasing intrauterine device using the hysteroscopic cold-knife surgery system: an original method in treatment of adenomyosis. Fertil Steril. 2021;116(4):1191–3. https://doi.org/10.1016/j.fertnstert.2021.05.113 . Paul PG, Shah M, Sridivya CV, Anusha RA, Paul G. Suture-fixation of a levonorgestrel-releasing intrauterine device under hysteroscopic guidance. Facts Views Vis Obgyn. 2023;15(4):355–8. https://doi.org/10.52054/FVVO.15.4.107 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5419588","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376568058,"identity":"2461e0f4-1cd6-41b9-83fc-74b6a805731a","order_by":0,"name":"Yi Yu","email":"","orcid":"","institution":"Obstetrics and Gynecology Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Yu","suffix":""},{"id":376568059,"identity":"c649f3c1-0e25-4cfe-bad7-e040f1c76c27","order_by":1,"name":"Qing Cong","email":"","orcid":"","institution":"Obstetrics and Gynecology Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Cong","suffix":""},{"id":376568060,"identity":"536842d6-30dc-4993-aa45-9a16cf41ee13","order_by":2,"name":"Long Sui","email":"","orcid":"","institution":"Obstetrics and Gynecology Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Long","middleName":"","lastName":"Sui","suffix":""},{"id":376568061,"identity":"1fcdc42d-da27-4180-b406-b0fcf115efc2","order_by":3,"name":"Hongwei Zhang","email":"","orcid":"","institution":"Obstetrics and Gynecology Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Hongwei","middleName":"","lastName":"Zhang","suffix":""},{"id":376568062,"identity":"5f97dbcb-6ec1-44e6-80e2-ea98473eef70","order_by":4,"name":"Limei Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYBACPmYgkcBQI8fPzHz4AVFa2CBajhlLtrOlGRCnBUIxJ244z6MgQZwWdu7EBw8Y2Bg3H+ZhMGCosYkmwmG8mw0SGGSYzQ7zHnjAcCwtt4EILdskEhjY2MwO8yUYMDYcJkrL9h8JDMw8xs08BhLEatkGDDFmCQNmErRslkgwOGYgcRgYyAnE+IWf/+zGjz8qaur7+w8ffvChxoawFgiAxWECccpHwSgYBaNgFBACACBzM0mDtaZBAAAAAElFTkSuQmCC","orcid":"","institution":"Obstetrics and Gynecology Hospital of Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Limei","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-11-09 03:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5419588/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5419588/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71545587,"identity":"076c185b-52b8-4024-9c96-14b71ed7e3d0","added_by":"auto","created_at":"2024-12-16 15:08:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":497300,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOperative procedures. A: \u003c/strong\u003euterine cavity was examined by hysteroscope, if polyps or other abnormalities were discovered, they were first treated to create a suitable fixation environment. \u003cstrong\u003eB,C: \u003c/strong\u003ethe two-tail filaments were surgically knotted several times to form a single knot and remaining tail filaments were cut off. Meanwhile, bilateral arms of the LNG-IUS were cut off to decrease its weight and resistance in the uterine cavity. \u003cstrong\u003eD: \u003c/strong\u003ewe inserted endoscopic scissors into the uterine fundus to form a cavity with a depth of 3-4mm and width of 1mm. \u003cstrong\u003eE,F: \u003c/strong\u003ethe head single knot of the LNG-IUS tail filaments was inserted into the myometrium of the uterine fundus by endoscopic scissors and the LNG-IUS was fixed successfully by hysteroscopy without suture.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5419588/v1/b7db07a068d37a51b4995b9e.png"},{"id":71545584,"identity":"f0771ab2-65d2-40f1-8d4d-307db7fdfc1a","added_by":"auto","created_at":"2024-12-16 15:08:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":269564,"visible":true,"origin":"","legend":"\u003cp\u003eHysteroscope was performed 6 months after surgery and showed that the single knot of the tail filament fused into the myometrium with LNG-IUD in the uterine cavity.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5419588/v1/6081b467a29ee46ec85834a1.png"},{"id":71545538,"identity":"c25cfaac-1de6-4f6f-80ca-211484653d07","added_by":"auto","created_at":"2024-12-16 15:08:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":58940,"visible":true,"origin":"","legend":"\u003cp\u003eA: mean hemoglobin in patients who had preoperative excessive menstrual flow. B: mean VAS scores in patients who had preoperative. C: mean PBAC scores in patients who had preoperative excessive menstrual flow\u003c/p\u003e\n\u003cp\u003e*Statistical significance compared with pre-OP (p \u0026lt; .001).\u003c/p\u003e\n\u003cp\u003ePBAC: pictorial blood loss assessment chart. VAS: mean visual analog PAIN scale\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5419588/v1/2474989f94e1dbd984c332e6.png"},{"id":71546773,"identity":"b85b107b-3737-44cf-bb16-2622c2be2f5c","added_by":"auto","created_at":"2024-12-16 15:16:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1455489,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5419588/v1/148b5d8b-053f-44c0-8f30-0e8e0d4b1116.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical application of a simplified hysteroscopic LNG-IUD non-suture fixation in the treatment of adenomyosis","fulltext":[{"header":"Background","content":"\u003cp\u003eAdenomyosis refers to invasion of endometrial glands and/or stroma into the myometrium and is a heterogeneous gynecologic disease with a range of clinical symptoms, the most common being menorrhagia, prolonged menstruation and progressive dysmenorrhea[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, total hysterectomy is considered to be the most effective treatment for adenomyosis. However, given that many patients have a strong desire to preserve the uterus, the treatment of adenomyosis should be personalized according to patient symptoms, age, and fertility requirements. Currently, medical therapy including contraceptives, danazol, LNG-IUD and gonadotropin-releasing hormone agonists (GnRHa) shows increasing efficacy in patients requiring control of symptoms or fertility treatments[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among these, the LNG-IUD is the most promising medical therapy[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This long-acting hormone-releasing uterine device releases high concentrations of progesterone locally, which can inhibit endometrial proliferation and promote apoptosis of endometrial cells[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have demonstrated that the LNG-IUD is an effective treatment option for adenomyosis, providing significant relief of dysmenorrhea and reducing menstrual volume while enabling women to maintain fertility[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, there are also some limitations to the suitability of the LNG-IUD for women with adenomyosis, as adenomyosis causes distortion or enlargement of the uterine cavity. Therefore, the LNG-IUD is more prone to expulsion in patients with adenomyosis[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. As Park reported, 37.5% of patients with large symptomatic adenomyosis and enlarged uteri experienced expulsion of the LNG-IUD, almost all cases occurring in the first 6 months postoperatively[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address this problem, this study presents an original and simplified approach using the hysteroscope for non-suture fixation of the LNG-IUD in the uterine of patients with adenomyosis who had a strong desire to preserve the uterus and had no immediate fertility requirements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e The study was approved by the Ethics Committee of Fudan University Obstetrics and Gynecology Hospital (approval number: 2022-52). Sixty-two patients with adenomyosis have providing informed consent and been successfully enrolled thus far. Data from patients with adenomyosis, who underwent non-suture fixation of the LNG-IUD at Obstetrics and Gynecology Hospital of Fudan University between October 2022 and July 2023, were collected from October 2022 to July 2024. Data analysis was performed in July 2024. Patients diagnosed with adenomyosis who expressed a strong desire to preserve their uterus and had no immediate fertility requirements were included in the study. Patients with a history of malignant tumor or GnRHa therapy in the preceding 6 months were excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMaterials\u003c/h3\u003e\n\u003cp\u003eThe materials used in this study included the following: the levonorgestrel-releasing intrauterine system (Mirena Manufacturer: Bayer; Standard Chinese Medicine: J20090144. 52 mg; 20 \u0026micro;g/24 h), hysteroscopic surgery system (Hangzhou Sode Medical Equipment Co., Ltd.), endoscopic scissors, endoscopic needle holder (Shenyang, Shenda Medical Equipment Co., Ltd.).\u003c/p\u003e\n\u003ch3\u003eOperative procedures\u003c/h3\u003e\n\u003cp\u003eUnder general anesthesia, with the patient positioned in the lithotomy position, hysteroscopy was performed using the HCSS. The key steps of the procedure were summarized as follows. First, the uterine cavity was examined by hysteroscope. If polyps, intrauterine adhesions, endometrial thickening or other abnormalities were discovered, they were treated first to create a suitable fixation environment. Second, the two-tail filaments were surgically knotted several times to form a single knot with the diameter of 2-3mm and the remaining tail filaments were cut off. Meanwhile, bilateral arms of the LNG-IUS were cut off to reduce its weight and resistance in the uterine cavity. Third, endoscopic scissors were inserted into the uterine fundus to form a cavity with a depth of 3-4mm and a width of 1mm. Fourth, the head of the single knot of the LNG-IUD tail filaments was inserted into the myometrium of the uterine fundus by endoscopic scissors and the LNG-IUD was fixed successfully by hysteroscopy without suture.\u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of interest was the expulsion rate of the LNG-IUD. Secondary outcomes included menstrual volume, dysmenorrhea, the level of hemoglobin, and incidence of adverse reactions, such as irregular bleeding, weight gain, and increased secretions. Blood loss was assessed using the Pictorial Blood Loss Assessment Chart (PBAC), a total score of 100 or more was considered to be menorrhagia[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The degree of dysmenorrhea was evaluated using Visual Analog Scale (VAS). The pain scale was assessed as follows: no pain (0 points), mild pain (1\u0026ndash;3 points), moderate pain (4\u0026ndash;6 points), and severe pain (7\u0026ndash;10 points)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePostoperative follow-up\u003c/h3\u003e\n\u003cp\u003eThe status of the LNG-IUD was evaluated by ultrasound and hysteroscopy. Menstrual flow was quantified with a pictorial blood assessment chart (PBAC), and the degree of dysmenorrhea was evaluated on a 100 mm visual analog scale (VAS). Both PBAC and VAS scores were recorded before and 1, 3, 6 and 12 months after insertion of the LNG-IUD. Adverse reactions to the LNG-IUD were recorded in the medical records, including menstrual pattern changes, abdominal discomfort, abnormal vaginal discharge, and climacteric symptoms.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were assessed for normality using the Kolmogorov-Smirnov test, and parametric data were analyzed using the \u003cem\u003et-\u003c/em\u003etest. Data are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), n (%), or median (range). Differences with p\u0026lt;0.05 were considered to be statistically significant. All data were analyzed using SPSS 20.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe hysteroscopic non-suture fixation of LNG-IUD was operated and the procedures were summarized in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Ultrasound demonstrated the position of the LNG-IUD was normal at 1, 3, 6 and 12 months after surgery. Hysteroscopy was performed 6 months after surgery, as shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eDuring the study period, sixty-two patients underwent non-suture fixation of the LNG-IUD. Although all procedures were successful, three patients were lost to follow-up. The procedure lasted for 10\u0026ndash;15 min. All patients had benign postoperative pathology reports. No intraoperative complications, such as uterine perforation, cervical laceration, water poisoning, or allergies, occurred in any patient. Preoperative clinical data are presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 59 patients with adenomyosis were included in this study: 41 (69.5%) experienced symptoms of dysmenorrhea, 45 (76.3%) experienced excessive menstrual flow, and 29 (49.2%) had a history of expulsion or removal.\u003c/p\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eProperative Clinical Data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge(y)[median(range)]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e39(28\u0026ndash;51)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSymptoms[n(%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExcessive menstrual flow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41(69.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDysmenorrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45(76.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6(10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerate pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30(50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHistory of expulsion or removal[n(%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30(50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29(49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin(g/L)[mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVAS scores[mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePBAC scores[mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e519.3\u0026thinsp;\u0026plusmn;\u0026thinsp;280.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAfter non-suture fixation of the LNG-IUD, when patients come for follow-up, we inquire about remission of symptoms and monitor the position of the LNG-IUD through ultrasound. The three pictures below clearly illustrate the changes.\u003c/p\u003e\n\u003cp\u003eAs observed in all investigated time windows, the mean(\u0026plusmn;\u0026thinsp;SD) preoperative hemoglobin level was 92.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4g/L, which increased significantly after the no-suture fixation of the LNG-IUD (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA). The VAS scores (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eB) and the PBAC scores (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eC) began to decrease in the first month after LNG-IUD fixation. The downward trend indicated by the broken line in the figures clearly demonstrated that in the one-year from the operation to follow-up, menstrual volume was significantly reduced, dysmenorrhea and quality of life after surgery were notably improved.\u003c/p\u003e\n\u003cp\u003eDuring the follow-up period, two patients (3.2%) experienced expulsion of the LNG-IUD at 8 and 12 months postoperatively. None of the patients underwent LNG-IUD removal. The most common side effect was irregular bleeding, which occurred in 44.3% of cases.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdenomyosis is a common gynecological disorder characterized by the invasion of endometrial glands and stroma into the myometrium, which results clinically in abnormal uterine bleeding, pelvic pain, and infertility[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. As the disease adversely affects the quality of life in terms of menstrual symptoms, fertility, and pregnancy outcomes, long-term and effective treatments for adenomyosis are necessary. Some scholars have proposed that adenomyosis may be associated with an increased risk of endometrial cancer since they share several altered molecular pathways and are both associated with similar local microenvironments[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, there is an urgent need for long-term and effective treatments for adenomyosis. Relevant studies have shown that the levonorgestrel-releasing intrauterine device can effectively treat the symptoms of abnormal uterine bleeding and dysmenorrhea in the long-term management of adenomyosis[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This is the theoretical basis for our research: the LNG-IUD is indeed a practical option for women requiring fertility-sparing management of adenomyosis.\u003c/p\u003e \u003cp\u003eHowever, high rates of LNG-IUD expulsion may deter patients from continuing treatment of adenomyosis, particularly those with a large uterus volume (\u0026gt;\u0026thinsp;150 mL)[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A prospective longitudinal study over a 60-month follow-up period (the longest follow-up of LNG-IUS for the treatment of adenomyosis to date) reported that the expulsion rate reached up to 21.8% when the patient had undergone pretreatment with GnRHa[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Approximately one-third of the patients had the LNG-IUD replaced, while more than half opted for alternative therapies, resulting in a waste of health care resources and increased anxiety among patients[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies have confirmed that pretreatment with gonadotropin-releasing hormone analog (GnRHa) is beneficial in reducing the size of uterus and it does greatly reduce the incidence of LNG-IUD expulsion[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. On the other hand, the adverse effects of GnRHa (e.g., menopausal symptoms and risk of osteoporosis) and the cost-benefit profile should be carefully considered. In contrast, our approach offers greater advantages due to fewer side effects and lower costs.\u003c/p\u003e \u003cp\u003eTo keep LNG-IUD from sliding off, several clinicians attempt to fix it in the uterus. To prevent separation, gynecologists stitch LNG-IUD into the uterine cavity. Zhu et al. first reported the fixation of LNG-IUD under hysteroscopy[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Paul G et al. demonstrated two methods for fixation of LNG-IUD under hysteroscopy[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In this study, we fixed the LNG-IUD under hysteroscopy without suture. To date, we have completed more than sixty cases of non-suture fixation of the LNG-IUD using this improved approach. The patient group is being followed up, with the follow-up period of 12 months, and only two cases of expulsion have occurred. Thus, we improved the procedure further, and we replaced the LNG-IUD tail thread that was fixed at the base of the uterus with a non absorbable surgical sutures (ETHI-CON). So far, no additional discharge of the LNG-IUD has occurred.\u003c/p\u003e \u003cp\u003eThis improved approach involves a better method of knotting in vitro and simplifies the process of LNG-IUD fixation without usage of endoscopic needle holder or endoscopic scissors. On the one hand, the operation time is greatly shortened; on the other hand, the method of knotting outside the body avoids repeatedly entering and leaving the uterus, thereby lowering the risk of intrauterine infection. In addition, this improved approach greatly reduces the difficulty of the operation, making it easier for clinicians to get started. With the improvements made by our team, the operation is simplified and easy to implement on a large scale, while remaining cost-effective.\u003c/p\u003e \u003cp\u003eHysteroscopic non-suture fixation of LNG‑IUD is an efficient technique that has achieved effective LNG‑IUD fixation in the uterine cavity, with the advantages of being easy to operate, having a short learning curve, requiring no special equipment or instruments not even the use of an endoscopic needle holder or endoscopic scissors, causing minimal surgical trauma, having a short operation time, allowing for quick recovery and easy removal. Therefore, this procedure is suitable to be performed in hospitals at all levels.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHysteroscopic non-suture fixation of the LNG-IUD can be a simplified and minimally invasive alternative treatment for patients with adenomyosis who have a history of LNG-IUD expulsion. The non-suture method greatly reduces the hysteroscopic difficulty of fixation and can be performed more efficiently in office.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;authors\u0026nbsp;declare that they have no\u0026nbsp;conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLimei Chen and Hongwei Zhang designed the study, Yi Yu, Qing Cong, Long Sui collected the data;\u0026nbsp;Yi Yu and Qing Cong analyzed the data and wrote the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe costs of the study were covered by the authors,\u0026nbsp;and\u0026nbsp;no funding was received from any institution or organization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics committee approval was granted by the Institutional Review Board of the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn informed consent form was obtained from the patients before their participation in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKho KA, Chen JS, Halvorson LM. Diagnosis, Evaluation, and Treatment of Adenomyosis. 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Facts Views Vis Obgyn. 2023;15(4):355\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.52054/FVVO.15.4.107\u003c/span\u003e\u003cspan address=\"10.52054/FVVO.15.4.107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Levonorgestrel-releasing intrauterine device, adenomyosis, hysteroscopy, fixation, non-suture","lastPublishedDoi":"10.21203/rs.3.rs-5419588/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5419588/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlacement of a levonorgestrel-releasing intrauterine device (LNG-IUD) is an effective treatment forpatients diagnosed with adenomyosis who had a strong desire to preserve the uterus and had no immediate fertility requirements. However, there are also some limitations to the suitability of the LNG-IUD for women with adenomyosis, as adenomyosis causes distortion or enlargement of the uterine cavity. Therefore, the LNG-IUD is more prone to expulsion in patients with adenomyosis. In this study, we aimed to show an original and simplified approach using the hysteroscope for non-suture fixation of LNG-IUD in patients with adenomyosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospectivecase series approved by the Ethics Committee of Obstetrics and Gynecology Hospital of Fudan University, sixty-two patients diagnosed with adenomyosis who had a strong desire to preserve the uterus and had no immediate fertility requirements in the short term were included in the study. They underwent hysteroscopic non-suture fixation of LNG-IUD. All patients underwent one-year postoperative follow-up to evaluate the LNG-IUD expulsion rate, postoperative efficacy and side effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSixty-two patients with adenomyosis underwent non-suture fixation with LNG-IUD and during the long-term postoperative follow-up, every patient experienced complete remission of their symptoms: a significant decrease in menstrual flow, relief of dysmenorrhea, and improvement in quality of life. Only two patients experienced expulsion of the LNG-IUD at 6 months and 10 months postoperatively, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHysteroscopic non-suture fixation of the LNG-IUD can be a more simplified and minimally invasive alternative treatment for patients with a history of LNG-IUD expulsion. The non-suture method greatly reduces the complexity of hysteroscopic fixation and can be performed more efficiently in office.\u003c/p\u003e","manuscriptTitle":"Clinical application of a simplified hysteroscopic LNG-IUD non-suture fixation in the treatment of adenomyosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 15:08:13","doi":"10.21203/rs.3.rs-5419588/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7aa4e4ff-4ed6-4cfa-809c-0bfa08fb82e2","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-16T15:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-16 15:08:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5419588","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5419588","identity":"rs-5419588","version":["v1"]},"buildId":"M1DPXKE8UapkOyQliHcFZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}