Progressively optimized fixation method for levonorgestrel-releasing intrauterine device

OBJECTIVE: To present an optimized fixation method for levonorgestrel-releasing intrauterine device (LNG-IUD) in adenomyosis patients, addressing high expulsion rates and improving clinical feasibility. DESIGN: Case series with a technical surgical video demonstrating the continuously improved hysteroscopic sutureless fixation of LNG-IUD. SUBJECTS: A representative case: a 43-year-old G4P2 woman with recurrent heavy menstrual bleeding and two prior LNG-IUD expulsions, with pretreatment uterine dimensions 91×82×81 mm. The patients included in this video gave consent for the publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites. EXPOSURE: The optimized fixation technique involves three key surgical steps: Step 1. Form Knot A: A sliding knot using the preattached polyethylene tail thread of LNG-IUD, allowing easy removal and reinsertion. Step 2. Form Knot B: A "loop knot" embedded into a 1- to 2-mm gap in the uterine fundus (depth 8 mm), designed to expand in narrow spaces for enhanced stability. Step 3. PROCEDURE: Performed via an integrated continuous flow hysteroscope (outer diameter 5.0 mm) by a single operator. MAIN OUTCOME MEASURES: Expulsion rate, operative time, intraoperative bleeding, ease of removal/reinsertion, and technical feasibility. RESULTS: The fixation procedure was successfully performed by a single gynecologist in 5 minutes, with the patient discharged home 30 minutes later. A total of 212 patients underwent this treatment between May 2022 and July 2024, with an expulsion rate of 1.4% (3/212). Among these cases, 159 patients had a uterine depth ≥9 cm (2 expulsions) and 45 patients had a history of expulsion (no expulsions). Although using the hysteroscopic cold-knife surgical system yields reliable results, our surgical method offers 10 advantages, including learning curve, instrument/consumable needs, preoperative cervical preparation, delivery method, removal/reinsertion difficulty, operative time, intraoperative bleeding, physician requirements, and expulsion rate. CONCLUSIONS: The optimized fixation method for LNG-IUD is effective in reducing expulsion rates in adenomyosis patients, with advantages of simplicity, ease of mastery, low instrument needs, ultralow expulsion rate, and high universality.