Suture fixation of the levonorgestrel-releasing intrauterine device with hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion

Suture fixation of the levonorgestrel-releasing intrauterine device with hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion | 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 Suture fixation of the levonorgestrel-releasing intrauterine device with hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion Min Mao, Yuan-Qin Gou, Ning Xu, Min Li, Meng-Xi Li, Zhi-Gui Luo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3712735/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 Objective: This study aimed to investigate the safety and efficacy of suture fixation of the levonorgestrel-releasing intrauterine device (LNG-IUD) through hysteroscope fortreatment of adenomyosis in patients at high risk of device expulsion. Methods: 21 patients with adenomyosis were fixed with the LNG-IUD on the uterine wall close to the base of the uterus by hysteroscopy. Subjects: with adenomyosis who are at high risk of device expulsion. Results: All 21 patients were successfully fixed with the LNG-IUD on the uterine wall close to the base of the uterus by hysteroscopy. Pictorial Blood Loss Assessment Chart (PBAC) and visual analogue scale (VAS) scores showed a significant decrease after 1 and 3 months after surgery compared with the baseline value. Serious IUD complications including expulsion and perforation were not observed. Conclusion:Suture fixation of the LNG-IUD through hysteroscope is a safe, effective, and minimally invasive surgical procedure to prevent IUD expulsion for the treatment of adenomyosis in patients who are at high risk of device expulsion. Levonorgestrel-releasing intrauterine device(LNG-IUD) Adenomyosis Hysteroscope Suture fixation Efficacy Figures Figure 1 1 Introduction Uterine adenomyosis is a common clinical gynecological disease, affecting approximately 20 to 35 percent of females [ 1 , 2 ] . Uterine adenomyosis causes hypertrophy and hyperplasia of the surrounding myometrium, as a result of endometrial glands and stroma disorder. The definitive pathogenesis of adenomyosis is unknown. Hypermenorrhea, secondary anemia, and dysmenorrhea are the typical symptoms of adenomyosis [ 3 ] that seriously affect the life quality of patients. The typical clinical feature is the mobile, diffusely enlarged, and soft uterus. The diagnosis approach of adenomyosis includes characteristic clinical symptoms, pelvic examination, and transvaginal ultrasound which is the first-line imaging choice since pathology evaluation of the uterus after hysterectomy is required to make a definitive diagnosis. Hormonal medications, such as GnRH analogs, aromatase inhibitors, and the oral GnRH antagonist elagolix used for the treatment of adenomyosis require daily administration. Enlargement of the uterus and recurrence of symptoms are usually documented within six months after hormonal medications are discontinued [ 4 – 9 ] . Since adenomyosis is confined to the uterine corpus, the effect of the surgical resection of the uterus is ideal, but it will cause the permanent loss of fertility and the uterus, which is usually unacceptable to women. Studies on UAE (uterine artery embolisation) for adenomyosis showed a 25 percent reduction in uterine volume and overall symptom reduction [ 10 – 12 ] . However, some data demonstrate high failure rates of treatment, with patients requiring additional intervention for persistent or recurrent symptoms [ 13 ] . The levonorgestrel-releasing intrauterine device (LNG-IUD) has steadily been replacing medication and surgery as a satisfactory management option for women with adenomyosis. The LNG-IUD is a T-shaped device that directly acts on the uterus with levonorgestrel, resulting in high endometrial concentration of LNG and low plasma LNG levels. Studies have shown that the LNG-IUD effectively improved adenomyosis-associated hypermenorrhea and dysmenorrhea [ 14 – 16 ] , with removal and replacement of the device every five years, which may give symptomatic relief until menopause. LNG-IUD would cause adverse reactions, such as breast tenderness, weight gain, and abnormal uterus bleeding. These adverse reactions generally do not cause patients to remove the IUD. However, one study reported a 25 percent LNG-IUD expulsion rate in patients with adenomyosis [ 17 ] . Risk factors for IUD expulsion include prior expulsion, a history of heavy menstrual bleeding or severe dysmenorrhea, postpartum or post-second trimester abortion, and prior all-vaginal deliveries. Women with adenomyosis who have expelled an LNG-IUD are prone to cause symptoms reoccurrence, leading to frequent examinations and treatments, even surgical intervention. Therefore, it is important to prevent and reduce IUD expulsion, especially in patients who are unlikely to receive hysterectomy surgeries. The first case of hysteroscopic suture fixation of the LNG-IUD was described by Zhu L in 2021 [ 18 ] , and there is limited data regarding the use of this approach to treat adenomyosis. As the feasibility and safety of this invasive procedure are unclear, we present our experience of 21 patients with adenomyosis treated with hysteroscopic suture fixation of the LNG-IUD to prevent device expulsion. 2 Materials and methods Research objects The diagnosis of adenomyosis was suggested by characteristic clinical manifestations (i.e., heavy menstrual bleeding or dysmenorrhea with uniformly enlarged uterus) and ultrasound findings. A total of 21 symptomatic adenomyosis patients admitted to Chengdu First People’s Hospital from October 2022 to May 2023 were enrolled to study. The inclusion criteria of the study were patients under 55 years old; patients who required uterus preservation; patients with symptoms of hypermenorrhea or dysmenorrhea; Patients without pregnancy; patients not allergic to LNG-IUS, and those with good compliance. The exclusion criteria of the study: Patients with leiomyoma; patients with cervical or endometrial pathology; Patients with breast tumors; patients who cannot be treated with hormones; patients with abnormal reproductive organs; patients with severe cervical laceration, and those with hormonal therapy within 6 months. All patients signed informed consent forms, and ethics approval was obtained from the Ethics Committee of Chengdu First People’s Hospital. Surgery procedure Before treatment, a series of examinations were carried out on the patients, including routine gynecological examination, transvaginal ultrasonography, and basic general check-ups to exclude contraindications. Preoperative cervical cytological examination and diagnostic uterine curettage were performed to exclude malignant diseases if necessary. All of the hysteroscopic suture fixations of the LNG-IUD (Mirena) operations were performed by one experienced surgeon (Yuan-Hong Li) under general anesthesia. We utilized glucose as the distention medium. The procedure was performed as follows: Step 1 join ethibond suture and LNG-IUD together; Step 2 Insertion and suture fixation of LNG-IUD; Step 3 Endoscopic knots; Step 4 Confirm the location of LNG-IUD. All patients were successfully performed with hysteroscopic suture fixation of the LNG-IUD on the intrauterine wall close to the base of the uterus with an ethibond suture through an endoscopic needle driver and a knot-pushing device (Fig. 1). Statistical analyses Statistical tests were performed using SPSS Statistics. Measurement data were expressed as the mean ± standard deviation, and compared between groups using the t-test, and correlation between groups using the linear regression. Enumeration data were presented by n (%). 3 Results Demographic and clinical characteristics of the patient population are reported in Table 1 . Ten patients who had experienced expulsion of the LNG-IUD were in group A. Eleven patients who were at high risk of IUD expulsion and did not place LNG-IUD before were in group B. We succeeded in hysteroscopic suture fixation of the LNG-IUD in 21 cases. The blood loss was minimal and no additional hemostatic methods were required. No differences were observed in age, BMI, parity, preoperative uterine depth, operative time, and intraoperative blood loss between the two groups (P > 0.05). In our study, it suggested that device expulsion was not correlated with the number of vaginal deliveries. The uterine depth had no significant difference compared with 10 cm (P > 0.05). Placement of LNG-IUD is not recommended in patients with uterine depth ≥ 10cm due to the high risk of expulsion. There were no complications or major adverse events at the time of surgery. The patients were discharged 24 hours postoperatively. One month after surgery, one patient in group A underwent a laparoscopic hysterectomy in another hospital due to pelvic infection disease and dysmenorrhea which was not alleviated. This patient was not included in the follow-up. Table 1 Demographic data and preoperative and operative condition of patients. Characteristics Mean ± SD or number (percent) Group A (n = 10) Group B (n = 11) Age in years 41.90 ± 1.35 41.64 ± 1.31 BMI in kg/m 2 22.14 ± 0.68 24.83 ± 1.28 preoperative uterine depth in cm 9.70 ± 1.25 9.32 ± 1.10 operative time in min 39.90 ± 7.72 42.72 ± 14.38 intraoperative blood loss in ml 17.00 ± 13.17 16.82 ± 12.30 Parity 0 0 3/(27.27%) 1 8/(80.00%) 6/(54.55%) 2 2/(20.00%) 2/(18.18%) Number of vaginal deliveries 0 8/(80.00%) 7/(63.64%) 1 2/(20.00%) 2/(18.18%) 2 0 2/(18.18%) Symptomatology on presentation Hypermenorrhea 1/(10.00%) 3/(27.27%) Dysmenorrhea 0 2/(18.18%) Hypermenorrhea and dysmenorrhea 9/(90.00%) 6/(54.55%) Patients who experienced 1 or more event of LNG-IUD self-expulsion in gorup A 1 6/(60.00%) 2 3/(30.00%) 3 1/(10.00%) Duration of keeping the previous LNG-IUD (month) in group A The first one 4.30 ± 3.53 The second one 3.50 ± 2.89 The third one 4.00 Abbreviations: LNG-IUD, levonorgestrel-releasing intrauterine device; SD, standard deviation; BMI, body mass index. Efficacy in patients after treatment are shown in Table 2 . The pictorial blood loss assessment chart (PBAC) was adopted to evaluate menstrual blood loss among patients [ 19 ] . A PBAC score ≥ 100 is used to predict heavy menstrual bleeding. Participants were instructed by the research doctor to fill in the PBAC for some menstrual cycles. A significant decrease in PBAC was found in the first 3 months after treatment, and there was a significant difference between 1 and 3 months after treatment in women and the baseline value (p < .001). Women with anemia, defined as a hemoglobin level < 110 g/L were using iron supplements. Among 20 patients, 16 women had anemia, among which ten women had a hemoglobin level of < 90 g/L before treatment. It turned out that after suture fixation of the LNG-IUD treatment, women had significantly higher hemoglobin levels than before (p < .001). The visual analogue scale (VAS), considered as the gold standard of pain measurement, was used to assess dysmenorrhea in patients and evaluate treatment response [ 20 ] . Each patient ticked her pain level within a pain score from 0 to 10. The highest perception of pain was recorded in their every observed menstrual cycle. The VAS of dysmenorrhea showed a significant decrease after 1 and 3 months of suture fixation of the LNG-IUD treatment (p < .001). Table 2 Suture fixation of the LNG-IUD through hysteroscope effectively prevent IUD expulsion. Baseline value 1 month after treatment 3 month after treatment Total PBAC score 150.75 ± 56.90 56.75 ± 43.45 * 46.00 ± 28.64 * The VAS score 6.75 ± 2.59 3.85 ± 1.57 * 2.75 ± 1.12 *, # Haemoglobin level in g/L 91.10 ± 21.92 105.80 ± 13.03 g/L * 114.25 ± 7.81 g/L *, # Data are shown as median ± standard deviation (Mean ± SD) * significant difference compared with the baseline value, p < .001. # significant difference compared with the value of the first month after treatment, p < .001. The changes in uterine size and the location of the LNG-IUD of each patient were assessed by transvaginal ultrasonography [ 21 ] . The uterine volume at 3 months of follow-up did not decrease significantly in comparison with the baseline uterine volume (P > 0.05). No patient experienced IUD expulsion at 3 months of follow-up. We also found that operative time was negatively correlated with the longitudinal diameter (Spearman r = 0.515, P < 0.05), the anteroposterior diameter (Spearman r = 0.517, P < 0.05), and the uterine volume of the uterus (Spearman r = 0.544, P 0.05). The longitudinal diameter, the anteroposterior diameter, the transverse diameter, the uterine volume of the uterus, and the uterine depth had no significant correlation with blood loss (P > 0.05). The adverse reactions in patients after treatment were recorded at every follow-up visit. We evaluated the number of patients who experienced adverse events. The total number of patients with adverse events was 13 (65.0%) in the first month and 10 (50.0%) in the first 3 months and 8 patients had multiple symptoms. Most patients complained of irregular bleeding, breast discomfort, abdominal discomfort, and weight gain. The use of LNG-IUD was associated with alteration in bleeding patterns including prolonged bleeding, unscheduled bleeding, and spotting. The changes in bleeding patterns were side effects of the hormone on the uterine lining and were not dangerous. Women in our study were able to tolerate the adverse reactions and it did not appear to impact the device continuation rates. No dyspareunia was observed in our study after treatment. 4 Discussion Adenomyosis is considered a notable health problem that challenges physicians all over the world. The etiology of adenomyosis is still unclear, and its presentation tends to be increasingly severe over time until menopause, and the response to treatments is not always successful. The LNG-IUD, originally designed for long-term contraceptives, is now recognized to provide non-contraceptive health benefits including severe dysmenorrhea, heavy menstrual bleeding, and endometrial hyperplasia [ 22 ] . The use of the LNG 52 IUD for the treatment of heavy menstrual bleeding is FDA-approved. Among patients using the LNG-IUD for the treatment of adenomyosis, the rate of LNG-IUD expulsion was found in about 25 percent of the cases. Women who have previously expelled an IUD are at higher risk of IUD expulsion again. Rates of reported IUD expulsion after prior expulsion range from 14 to 31 percent [ 23 , 24 ] . Enlargement of the uterus and recurrence of symptoms are usually documented within six months after the LNG-IUD expulsion. In the present research, we performed hysteroscopic suture fixation of the LNG-IUD in the uterine cavity to prevent the IUD expulsion, which did not affect the structure of the LNG-IUD, and the safety and efficacy of the technique were evaluated. Patients in our study who have a high risk of IUD expulsion or have experienced an IUD expulsion were desired to use the LNG-IUD for treatment. Hysteroscopic suture fixation of the LNG-IUD was significantly effective in improving heavy menstrual bleeding and alleviating pain without LNG-IUD expulsion. Approximately 85 percent of women had PBAC scores ≥ 100 and had anemia at baseline. Three months after suture fixation of the LNG-IUD and iron supplements treatment, patients got smaller PBAC scores and decreased VAS scores, and hemoglobin levels were increased to normal levels in most patients. All follow-up patients reported obvious relief of menorrhagia and dysmenorrhea; Serious IUD complications including expulsion and perforation were not observed in our study. Pelvic inflammatory disease (PID) was observed in one patient (4.76 percent) after the surgery. Less serious side effects including irregular bleeding, leukorrhea, abdomen discomfort, headache, breast discomfort, and weight gain were observed, which are consistent with adverse reactions reported for LNG-IUD insertion in the literature. Further, there is no development of new side effects than that has been reported about LNG-IUD insertion before. All patients in our study did not have impairment of sexual activity after treatment. The uterine volume after suture fixation of LNG-IUD did not decrease significantly compared to baseline after 3 months of treatment. The time of follow-up needs to be extended to identify the effect on uterine volume. We here summarized several experiences on precautions during surgery. First, the cervix needs to be fully dilated before surgery. Second, in the suture technique, the needle should be inserted into the superficial layer of the myometrium to ensure an effective suture and prevent withdrawing the needle difficultly. Third, to determine the knot position during the hysteroscopic surgery, we can make scale marks on the knotting rod, and compare them to the preoperative depth of the uterine. In our study, hysteroscopic suture fixation of an LNG-IUD for adenomyosis treatment had no more adverse reactions than placement of the LNG-IUD. This study has demonstrated the safety and feasibility of the surgery. We recommend this procedure as a first-line option for the treatment of adenomyosis patients at high risk of IUD expulsion. The disadvantage of this approach is that suture fixation and removal of the LNG-IUD are procedures that should be performed through a hysteroscope, which may increase the financial burden on patients. However, the overall cost decreases year by year, as no additional expenditure is required. Preoperative screening of women at high risk for IUD expulsion must be very cautious because the hysteroscopic surgery itself leads to increased major perioperative complications. Further research is needed to clarify the relevant indicators for adenomyosis patients with a high risk of IUD expulsion. The most important limitation of the present study was: that due to the small number of patients in the study, this may limit the generalizability of the results. Nonetheless, this study was the first to evaluate the safety and efficacy of hysteroscopic suture fixation of the LNG-IUD performed in adenomyosis patients. 5 Conclusions Hysteroscopic suture fixation of the LNG-IUD can prevent the IUD expulsion from the uterus without affecting the efficacy and increasing adverse reactions of the LNG-IUD. Therefore, hysteroscopic suture fixation of the LNG-IUD is worthy of clinical application in adenomyosis patients with a higher risk of LNG-IUD expulsion. Declarations Funding Not applicable Conflicts of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics approval Ethical review and approval were not required for the study on human participants in accordance with the local legislation and institution requirements. The patients/ participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article. Availability of data and materials The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors. References Abbott JA. Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. Best Pract Res Clin Obstet Gynaecol. 2017. 40: 68-81. Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L. Adenomyosis: epidemiological factors. Best Pract Res Clin Obstet Gynaecol. 2006. 20(4): 465-77. McElin TW, Bird CC. Adenomyosis of the uterus. Obstet Gynecol Annu. 1974. 3(0): 425-41. Osuga Y, Fujimoto-Okabe H, Hagino A. Evaluation of the efficacy and safety of dienogest in the treatment of painful symptoms in patients with adenomyosis: a randomized, double-blind, multicenter, placebo-controlled study. Fertil Steril. 2017. 108(4): 673-678. Osuga Y, Watanabe M, Hagino A. Long-term use of dienogest in the treatment of painful symptoms in adenomyosis. J Obstet Gynaecol Res. 2017. 43(9): 1441-1448. Huang FJ, Kung FT, Chang SY, Hsu TY. Effects of short-course buserelin therapy on adenomyosis. A report of two cases. J Reprod Med. 1999. 44(8): 741-4. Kitawaki J. Adenomyosis: the pathophysiology of an oestrogen-dependent disease. Best Pract Res Clin Obstet Gynaecol. 2006. 20(4): 493-502. Kavoussi SK, Esqueda AS, Jukes LM. Elagolix to medically treat a uterine adenomyoma: A case report. Eur J Obstet Gynecol Reprod Biol. 2020. 247: 266-267. Schlaff WD, Ackerman RT, Al-Hendy A, et al. Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. N Engl J Med. 2020. 382(4): 328-340. Nijenhuis RJ, Smeets AJ, Morpurgo M, et al. Uterine artery embolisation for symptomatic adenomyosis with polyzene F-coated hydrogel microspheres: three-year clinical follow-up using UFS-QoL questionnaire. Cardiovasc Intervent Radiol. 2015. 38(1): 65-71. de Bruijn AM, Smink M, Hehenkamp W, et al. Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire. Cardiovasc Intervent Radiol. 2017. 40(9): 1344-1350. Kim MD, Kim S, Kim NK, et al. Long-term results of uterine artery embolization for symptomatic adenomyosis. AJR Am J Roentgenol. 2007. 188(1): 176-81. Pelage JP, Jacob D, Fazel A, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology. 2005. 234(3): 948-53. Fong YF, Singh K. Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system. Contraception. 1999. 60(3): 173-5. Fedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997. 68(3): 426-9. Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception. 2009. 79(3): 189-93. Peng FS, Wu MY, Yang JH, Chen SU, Ho HN, Yang YS. Insertion of the Mirena intrauterine system for treatment of adenomyosis-associated menorrhagia: a novel method. Taiwan J Obstet Gynecol. 2010. 49(2): 160-4. Zhu L, Yang X, Cao B, Tang S, Tong J. 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): 1191-1193. Higham JM, O', Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol. 1990. 97(8): 734-9. Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M. Systematic review of endometriosis pain assessment: how to choose a scale. Hum Reprod Update. 2015. 21(1): 136-52. Cho S, Nam A, Kim H, et al. Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis. Am J Obstet Gynecol. 2008. 198(4): 373.e1-7. Baker WD, Pierce SR, Mills AM, Gehrig PA, Duska LR. Nonoperative management of atypical endometrial hyperplasia and grade 1 endometrial cancer with the levonorgestrel intrauterine device in medically ill post-menopausal women. Gynecol Oncol. 2017. 146(1): 34-38. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014. 123(3): 585-592. Bahamondes L, Díaz J, Marchi NM, Petta CA, Cristofoletti ML, Gomez G. Performance of copper intrauterine devices when inserted after an expulsion. Hum Reprod. 1995. 10(11): 2917-8. 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. We do this by developing innovative software and high quality services for the global research community. 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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-3712735","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":257481875,"identity":"385e358a-7cee-40bb-b4b2-efd45982019e","order_by":0,"name":"Min Mao","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Mao","suffix":""},{"id":257481883,"identity":"e46bf0c1-d3f8-4581-af5a-f6b0a598a7be","order_by":1,"name":"Yuan-Qin Gou","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuan-Qin","middleName":"","lastName":"Gou","suffix":""},{"id":257481887,"identity":"6ff74df9-649d-4d4f-8148-fe21bea75c31","order_by":2,"name":"Ning Xu","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ning","middleName":"","lastName":"Xu","suffix":""},{"id":257481893,"identity":"204d2410-588d-481b-927b-262caa768265","order_by":3,"name":"Min Li","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Li","suffix":""},{"id":257481898,"identity":"f1494fab-60e4-477c-825c-5e36b3143531","order_by":4,"name":"Meng-Xi Li","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Meng-Xi","middleName":"","lastName":"Li","suffix":""},{"id":257481899,"identity":"241e0b52-72f2-499c-90da-fa698f9b2639","order_by":5,"name":"Zhi-Gui Luo","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhi-Gui","middleName":"","lastName":"Luo","suffix":""},{"id":257481903,"identity":"26db8e7f-f2ff-417a-8a0c-2d2b63a1542e","order_by":6,"name":"Yuan-Hong Li","email":"","orcid":"","institution":"Chengdu First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuan-Hong","middleName":"","lastName":"Li","suffix":""},{"id":257481907,"identity":"547b983a-c7e2-4ca3-8035-1ebd6f69250a","order_by":7,"name":"Yu Tong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYDACZgglx8befoA0LcZ8PGcSSLMscZ6EgwFxSuXb2Z9JMLYdTm+TYEhg+FGxjbAWxmYeM5CW3DbpxgOMPWduE9bCzMzDBtEicyCBmbGNCC1szFCHsUkkGBCnhYeZAeywBOK1SDDzGFswnEs3bAMG8kGi/CLff/zhDYYya3n59vaDD35UEKEFBJj/skEYB4hTDwZ/SFA7CkbBKBgFIw8AABP8MiEWxLIvAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Yu","middleName":"","lastName":"Tong","suffix":""}],"badges":[],"createdAt":"2023-12-06 03:14:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3712735/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3712735/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":47989812,"identity":"9a6d294c-35b8-4e75-bb48-31b77ae8225d","added_by":"auto","created_at":"2023-12-11 15:10:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":982378,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3712735/v1/5589e55c97ac8030ad4390f8.png"},{"id":48235377,"identity":"585b9d2e-bcfa-41f4-b2a9-cc97239dde81","added_by":"auto","created_at":"2023-12-14 21:52:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1575505,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3712735/v1/94ebdc02-cd4c-4e57-942b-90a86d15784a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Suture fixation of the levonorgestrel-releasing intrauterine device with hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eUterine adenomyosis is a common clinical gynecological disease, affecting approximately 20 to 35 percent of females\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Uterine adenomyosis causes hypertrophy and hyperplasia of the surrounding myometrium, as a result of endometrial glands and stroma disorder. The definitive pathogenesis of adenomyosis is unknown. Hypermenorrhea, secondary anemia, and dysmenorrhea are the typical symptoms of adenomyosis\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e that seriously affect the life quality of patients. The typical clinical feature is the mobile, diffusely enlarged, and soft uterus. The diagnosis approach of adenomyosis includes characteristic clinical symptoms, pelvic examination, and transvaginal ultrasound which is the first-line imaging choice since pathology evaluation of the uterus after hysterectomy is required to make a definitive diagnosis. Hormonal medications, such as GnRH analogs, aromatase inhibitors, and the oral GnRH antagonist elagolix used for the treatment of adenomyosis require daily administration. Enlargement of the uterus and recurrence of symptoms are usually documented within six months after hormonal medications are discontinued\u003csup\u003e[\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Since adenomyosis is confined to the uterine corpus, the effect of the surgical resection of the uterus is ideal, but it will cause the permanent loss of fertility and the uterus, which is usually unacceptable to women. Studies on UAE (uterine artery embolisation) for adenomyosis showed a 25 percent reduction in uterine volume and overall symptom reduction\u003csup\u003e[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. However, some data demonstrate high failure rates of treatment, with patients requiring additional intervention for persistent or recurrent symptoms\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe levonorgestrel-releasing intrauterine device (LNG-IUD) has steadily been replacing medication and surgery as a satisfactory management option for women with adenomyosis. The LNG-IUD is a T-shaped device that directly acts on the uterus with levonorgestrel, resulting in high endometrial concentration of LNG and low plasma LNG levels. Studies have shown that the LNG-IUD effectively improved adenomyosis-associated hypermenorrhea and dysmenorrhea\u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, with removal and replacement of the device every five years, which may give symptomatic relief until menopause. LNG-IUD would cause adverse reactions, such as breast tenderness, weight gain, and abnormal uterus bleeding. These adverse reactions generally do not cause patients to remove the IUD. However, one study reported a 25 percent LNG-IUD expulsion rate in patients with adenomyosis\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Risk factors for IUD expulsion include prior expulsion, a history of heavy menstrual bleeding or severe dysmenorrhea, postpartum or post-second trimester abortion, and prior all-vaginal deliveries. Women with adenomyosis who have expelled an LNG-IUD are prone to cause symptoms reoccurrence, leading to frequent examinations and treatments, even surgical intervention. Therefore, it is important to prevent and reduce IUD expulsion, especially in patients who are unlikely to receive hysterectomy surgeries. The first case of hysteroscopic suture fixation of the LNG-IUD was described by Zhu L in 2021\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, and there is limited data regarding the use of this approach to treat adenomyosis. As the feasibility and safety of this invasive procedure are unclear, we present our experience of 21 patients with adenomyosis treated with hysteroscopic suture fixation of the LNG-IUD to prevent device expulsion.\u003c/p\u003e"},{"header":"2 Materials and methods","content":"\u003cp\u003e \u003cb\u003eResearch objects\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe diagnosis of adenomyosis was suggested by characteristic clinical manifestations (i.e., heavy menstrual bleeding or dysmenorrhea with uniformly enlarged uterus) and ultrasound findings. A total of 21 symptomatic adenomyosis patients admitted to Chengdu First People\u0026rsquo;s Hospital from October 2022 to May 2023 were enrolled to study. The inclusion criteria of the study were patients under 55 years old; patients who required uterus preservation; patients with symptoms of hypermenorrhea or dysmenorrhea; Patients without pregnancy; patients not allergic to LNG-IUS, and those with good compliance. The exclusion criteria of the study: Patients with leiomyoma; patients with cervical or endometrial pathology; Patients with breast tumors; patients who cannot be treated with hormones; patients with abnormal reproductive organs; patients with severe cervical laceration, and those with hormonal therapy within 6 months. All patients signed informed consent forms, and ethics approval was obtained from the Ethics Committee of Chengdu First People\u0026rsquo;s Hospital.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSurgery procedure\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBefore treatment, a series of examinations were carried out on the patients, including routine gynecological examination, transvaginal ultrasonography, and basic general check-ups to exclude contraindications. Preoperative cervical cytological examination and diagnostic uterine curettage were performed to exclude malignant diseases if necessary. All of the hysteroscopic suture fixations of the LNG-IUD (Mirena) operations were performed by one experienced surgeon (Yuan-Hong Li) under general anesthesia. We utilized glucose as the distention medium. The procedure was performed as follows: Step 1 join ethibond suture and LNG-IUD together; Step 2 Insertion and suture fixation of LNG-IUD; Step 3 Endoscopic knots; Step 4 Confirm the location of LNG-IUD. All patients were successfully performed with hysteroscopic suture fixation of the LNG-IUD on the intrauterine wall close to the base of the uterus with an ethibond suture through an endoscopic needle driver and a knot-pushing device (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analyses\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStatistical tests were performed using SPSS Statistics. Measurement data were expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and compared between groups using the t-test, and correlation between groups using the linear regression. Enumeration data were presented by n (%).\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eDemographic and clinical characteristics of the patient population are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Ten patients who had experienced expulsion of the LNG-IUD were in group A. Eleven patients who were at high risk of IUD expulsion and did not place LNG-IUD before were in group B. We succeeded in hysteroscopic suture fixation of the LNG-IUD in 21 cases. The blood loss was minimal and no additional hemostatic methods were required. No differences were observed in age, BMI, parity, preoperative uterine depth, operative time, and intraoperative blood loss between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In our study, it suggested that device expulsion was not correlated with the number of vaginal deliveries. The uterine depth had no significant difference compared with 10 cm (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Placement of LNG-IUD is not recommended in patients with uterine depth\u0026thinsp;\u0026ge;\u0026thinsp;10cm due to the high risk of expulsion. There were no complications or major adverse events at the time of surgery. The patients were discharged 24 hours postoperatively. One month after surgery, one patient in group A underwent a laparoscopic hysterectomy in another hospital due to pelvic infection disease and dysmenorrhea which was not alleviated. This patient was not included in the follow-up.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data and preoperative and operative condition of patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or number (percent)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI in kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epreoperative uterine depth in cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eoperative time in min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.90\u0026thinsp;\u0026plusmn;\u0026thinsp;7.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.72\u0026thinsp;\u0026plusmn;\u0026thinsp;14.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eintraoperative blood loss in ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.82\u0026thinsp;\u0026plusmn;\u0026thinsp;12.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/(27.27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/(80.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/(54.55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/(20.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/(18.18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNumber of vaginal deliveries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/(80.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/(63.64%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/(20.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/(18.18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/(18.18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSymptomatology on presentation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypermenorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/(10.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/(27.27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysmenorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/(18.18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypermenorrhea and dysmenorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/(90.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/(54.55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePatients who experienced 1 or more event of LNG-IUD self-expulsion in gorup A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/(60.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/(30.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/(10.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDuration of keeping the previous LNG-IUD (month) in group A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe first one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.30\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe second one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe third one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eAbbreviations: LNG-IUD, levonorgestrel-releasing intrauterine device; SD, standard deviation; BMI, body mass index.\u0026nbsp;\u003c/p\u003e \u003cp\u003eEfficacy in patients after treatment are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The pictorial blood loss assessment chart (PBAC) was adopted to evaluate menstrual blood loss among patients\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. A PBAC score\u0026thinsp;\u0026ge;\u0026thinsp;100 is used to predict heavy menstrual bleeding. Participants were instructed by the research doctor to fill in the PBAC for some menstrual cycles. A significant decrease in PBAC was found in the first 3 months after treatment, and there was a significant difference between 1 and 3 months after treatment in women and the baseline value (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Women with anemia, defined as a hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;110 g/L were using iron supplements. Among 20 patients, 16 women had anemia, among which ten women had a hemoglobin level of \u0026lt;\u0026thinsp;90 g/L before treatment. It turned out that after suture fixation of the LNG-IUD treatment, women had significantly higher hemoglobin levels than before (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The visual analogue scale (VAS), considered as the gold standard of pain measurement, was used to assess dysmenorrhea in patients and evaluate treatment response\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Each patient ticked her pain level within a pain score from 0 to 10. The highest perception of pain was recorded in their every observed menstrual cycle. The VAS of dysmenorrhea showed a significant decrease after 1 and 3 months of suture fixation of the LNG-IUD treatment (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSuture fixation of the LNG-IUD through hysteroscope effectively prevent IUD expulsion.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 month after treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 month after treatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PBAC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e150.75\u0026thinsp;\u0026plusmn;\u0026thinsp;56.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.75\u0026thinsp;\u0026plusmn;\u0026thinsp;43.45 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.00\u0026thinsp;\u0026plusmn;\u0026thinsp;28.64\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe VAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.75\u0026thinsp;\u0026plusmn;\u0026thinsp;2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003csup\u003e*, #\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemoglobin level in g/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e91.10\u0026thinsp;\u0026plusmn;\u0026thinsp;21.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105.80\u0026thinsp;\u0026plusmn;\u0026thinsp;13.03 g/L \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114.25\u0026thinsp;\u0026plusmn;\u0026thinsp;7.81 g/L\u003csup\u003e*, #\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are shown as median\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e*\u003c/sup\u003esignificant difference compared with the baseline value, p\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e#\u003c/sup\u003e significant difference compared with the value of the first month after treatment, p\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe changes in uterine size and the location of the LNG-IUD of each patient were assessed by transvaginal ultrasonography\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. The uterine volume at 3 months of follow-up did not decrease significantly in comparison with the baseline uterine volume (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No patient experienced IUD expulsion at 3 months of follow-up. We also found that operative time was negatively correlated with the longitudinal diameter (Spearman r\u0026thinsp;=\u0026thinsp;0.515, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), the anteroposterior diameter (Spearman r\u0026thinsp;=\u0026thinsp;0.517, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the uterine volume of the uterus (Spearman r\u0026thinsp;=\u0026thinsp;0.544, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The transverse diameter of the uterus and uterine depth had no significant correlation with operation time (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The longitudinal diameter, the anteroposterior diameter, the transverse diameter, the uterine volume of the uterus, and the uterine depth had no significant correlation with blood loss (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe adverse reactions in patients after treatment were recorded at every follow-up visit. We evaluated the number of patients who experienced adverse events. The total number of patients with adverse events was 13 (65.0%) in the first month and 10 (50.0%) in the first 3 months and 8 patients had multiple symptoms. Most patients complained of irregular bleeding, breast discomfort, abdominal discomfort, and weight gain. The use of LNG-IUD was associated with alteration in bleeding patterns including prolonged bleeding, unscheduled bleeding, and spotting. The changes in bleeding patterns were side effects of the hormone on the uterine lining and were not dangerous. Women in our study were able to tolerate the adverse reactions and it did not appear to impact the device continuation rates. No dyspareunia was observed in our study after treatment.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eAdenomyosis is considered a notable health problem that challenges physicians all over the world. The etiology of adenomyosis is still unclear, and its presentation tends to be increasingly severe over time until menopause, and the response to treatments is not always successful. The LNG-IUD, originally designed for long-term contraceptives, is now recognized to provide non-contraceptive health benefits including severe dysmenorrhea, heavy menstrual bleeding, and endometrial hyperplasia\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. The use of the LNG 52 IUD for the treatment of heavy menstrual bleeding is FDA-approved. Among patients using the LNG-IUD for the treatment of adenomyosis, the rate of LNG-IUD expulsion was found in about 25 percent of the cases. Women who have previously expelled an IUD are at higher risk of IUD expulsion again. Rates of reported IUD expulsion after prior expulsion range from 14 to 31 percent\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Enlargement of the uterus and recurrence of symptoms are usually documented within six months after the LNG-IUD expulsion. In the present research, we performed hysteroscopic suture fixation of the LNG-IUD in the uterine cavity to prevent the IUD expulsion, which did not affect the structure of the LNG-IUD, and the safety and efficacy of the technique were evaluated.\u003c/p\u003e \u003cp\u003ePatients in our study who have a high risk of IUD expulsion or have experienced an IUD expulsion were desired to use the LNG-IUD for treatment. Hysteroscopic suture fixation of the LNG-IUD was significantly effective in improving heavy menstrual bleeding and alleviating pain without LNG-IUD expulsion. Approximately 85 percent of women had PBAC scores\u0026thinsp;\u0026ge;\u0026thinsp;100 and had anemia at baseline. Three months after suture fixation of the LNG-IUD and iron supplements treatment, patients got smaller PBAC scores and decreased VAS scores, and hemoglobin levels were increased to normal levels in most patients. All follow-up patients reported obvious relief of menorrhagia and dysmenorrhea; Serious IUD complications including expulsion and perforation were not observed in our study. Pelvic inflammatory disease (PID) was observed in one patient (4.76 percent) after the surgery. Less serious side effects including irregular bleeding, leukorrhea, abdomen discomfort, headache, breast discomfort, and weight gain were observed, which are consistent with adverse reactions reported for LNG-IUD insertion in the literature. Further, there is no development of new side effects than that has been reported about LNG-IUD insertion before. All patients in our study did not have impairment of sexual activity after treatment. The uterine volume after suture fixation of LNG-IUD did not decrease significantly compared to baseline after 3 months of treatment. The time of follow-up needs to be extended to identify the effect on uterine volume.\u003c/p\u003e \u003cp\u003eWe here summarized several experiences on precautions during surgery. First, the cervix needs to be fully dilated before surgery. Second, in the suture technique, the needle should be inserted into the superficial layer of the myometrium to ensure an effective suture and prevent withdrawing the needle difficultly. Third, to determine the knot position during the hysteroscopic surgery, we can make scale marks on the knotting rod, and compare them to the preoperative depth of the uterine.\u003c/p\u003e\u003cp\u003eIn our study, hysteroscopic suture fixation of an LNG-IUD for adenomyosis treatment had no more adverse reactions than placement of the LNG-IUD. This study has demonstrated the safety and feasibility of the surgery. We recommend this procedure as a first-line option for the treatment of adenomyosis patients at high risk of IUD expulsion. The disadvantage of this approach is that suture fixation and removal of the LNG-IUD are procedures that should be performed through a hysteroscope, which may increase the financial burden on patients. However, the overall cost decreases year by year, as no additional expenditure is required. Preoperative screening of women at high risk for IUD expulsion must be very cautious because the hysteroscopic surgery itself leads to increased major perioperative complications. Further research is needed to clarify the relevant indicators for adenomyosis patients with a high risk of IUD expulsion. The most important limitation of the present study was: that due to the small number of patients in the study, this may limit the generalizability of the results. Nonetheless, this study was the first to evaluate the safety and efficacy of hysteroscopic suture fixation of the LNG-IUD performed in adenomyosis patients.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eHysteroscopic suture fixation of the LNG-IUD can prevent the IUD expulsion from the uterus without affecting the efficacy and increasing adverse reactions of the LNG-IUD. Therefore, hysteroscopic suture fixation of the LNG-IUD is worthy of clinical application in adenomyosis patients with a higher risk of LNG-IUD expulsion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest Statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical review and approval were not required for the study on human participants in\u0026nbsp;accordance with the local legislation\u0026nbsp;and institution requirements. The patients/ participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.\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, further inquiries can be directed to the corresponding authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbbott JA. Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. Best Pract Res Clin Obstet Gynaecol. 2017. 40: 68-81.\u003c/li\u003e\n \u003cli\u003eVercellini P, Vigan\u0026ograve; P, Somigliana E, Daguati R, Abbiati A, Fedele L. Adenomyosis: epidemiological factors. Best Pract Res Clin Obstet Gynaecol. 2006. 20(4): 465-77.\u003c/li\u003e\n \u003cli\u003eMcElin TW, Bird CC. Adenomyosis of the uterus. 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Elagolix to medically treat a uterine adenomyoma: A case report. Eur J Obstet Gynecol Reprod Biol. 2020. 247: 266-267.\u003c/li\u003e\n \u003cli\u003eSchlaff WD, Ackerman RT, Al-Hendy A, et al. Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. N Engl J Med. 2020. 382(4): 328-340.\u003c/li\u003e\n \u003cli\u003eNijenhuis RJ, Smeets AJ, Morpurgo M, et al. Uterine artery embolisation for symptomatic adenomyosis with polyzene F-coated hydrogel microspheres: three-year clinical follow-up using UFS-QoL questionnaire. Cardiovasc Intervent Radiol. 2015. 38(1): 65-71.\u003c/li\u003e\n \u003cli\u003ede Bruijn AM, Smink M, Hehenkamp W, et al. Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire. Cardiovasc Intervent Radiol. 2017. 40(9): 1344-1350.\u003c/li\u003e\n \u003cli\u003eKim MD, Kim S, Kim NK, et al. Long-term results of uterine artery embolization for symptomatic adenomyosis. AJR Am J Roentgenol. 2007. 188(1): 176-81.\u003c/li\u003e\n \u003cli\u003ePelage JP, Jacob D, Fazel A, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology. 2005. 234(3): 948-53.\u003c/li\u003e\n \u003cli\u003eFong YF, Singh K. Medical treatment of a grossly enlarged adenomyotic uterus with the levonorgestrel-releasing intrauterine system. Contraception. 1999. 60(3): 173-5.\u003c/li\u003e\n \u003cli\u003eFedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997. 68(3): 426-9.\u003c/li\u003e\n \u003cli\u003eSheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis. Contraception. 2009. 79(3): 189-93.\u003c/li\u003e\n \u003cli\u003ePeng FS, Wu MY, Yang JH, Chen SU, Ho HN, Yang YS. Insertion of the Mirena intrauterine system for treatment of adenomyosis-associated menorrhagia: a novel method. Taiwan J Obstet Gynecol. 2010. 49(2): 160-4.\u003c/li\u003e\n \u003cli\u003eZhu L, Yang X, Cao B, Tang S, Tong J. 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): 1191-1193.\u003c/li\u003e\n \u003cli\u003eHigham JM, O\u0026amp;#x27, Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol. 1990. 97(8): 734-9.\u003c/li\u003e\n \u003cli\u003eBourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M. Systematic review of endometriosis pain assessment: how to choose a scale. Hum Reprod Update. 2015. 21(1): 136-52.\u003c/li\u003e\n \u003cli\u003eCho S, Nam A, Kim H, et al. Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis. Am J Obstet Gynecol. 2008. 198(4): 373.e1-7.\u003c/li\u003e\n \u003cli\u003eBaker WD, Pierce SR, Mills AM, Gehrig PA, Duska LR. Nonoperative management of atypical endometrial hyperplasia and grade 1 endometrial cancer with the levonorgestrel intrauterine device in medically ill post-menopausal women. Gynecol Oncol. 2017. 146(1): 34-38.\u003c/li\u003e\n \u003cli\u003eAoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014. 123(3): 585-592.\u003c/li\u003e\n \u003cli\u003eBahamondes L, D\u0026iacute;az J, Marchi NM, Petta CA, Cristofoletti ML, Gomez G. Performance of copper intrauterine devices when inserted after an expulsion. Hum Reprod. 1995. 10(11): 2917-8.\u003c/li\u003e\n\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(LNG-IUD), Adenomyosis, Hysteroscope, Suture fixation, Efficacy","lastPublishedDoi":"10.21203/rs.3.rs-3712735/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3712735/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: This study aimed to investigate the safety and efficacy of suture fixation of the levonorgestrel-releasing intrauterine device (LNG-IUD) through hysteroscope fortreatment of adenomyosis in patients at high risk of device expulsion.\u003c/p\u003e\n\u003cp\u003eMethods: 21 patients with adenomyosis were fixed with the LNG-IUD on the uterine wall close to the base of the uterus by hysteroscopy.\u003c/p\u003e\n\u003cp\u003eSubjects: with adenomyosis who are at high risk of device expulsion.\u003c/p\u003e\n\u003cp\u003eResults: All 21 patients were successfully fixed with the LNG-IUD on the uterine wall close to the base of the uterus by hysteroscopy. Pictorial Blood Loss Assessment Chart (PBAC) and visual analogue scale (VAS) scores showed a significant decrease after 1 and 3 months after surgery compared with the baseline value. Serious IUD complications including expulsion and perforation were not observed.\u003c/p\u003e\n\u003cp\u003eConclusion:Suture fixation of the LNG-IUD through hysteroscope is a safe, effective, and minimally invasive surgical procedure to prevent IUD expulsion for the treatment of adenomyosis in patients who are at high risk of device expulsion.\u003c/p\u003e","manuscriptTitle":"Suture fixation of the levonorgestrel-releasing intrauterine device with hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-11 15:07:01","doi":"10.21203/rs.3.rs-3712735/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":"9a564817-dd25-4266-952d-5315f2a2671c","owner":[],"postedDate":"December 11th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-14T21:44:14+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-11 15:07:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3712735","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3712735","identity":"rs-3712735","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}