A Modified Hysteroscopic suture fixation of LNG-IUS: a case report video article

LevoNorGestrel Intrauterine System (LNG- IUS) has a number of applications, both contraceptive and non-contraceptive benefits. Its non-contraceptive use has benefited several gynecological conditions such as adenomyosis, endometriosis, Abnormal Uterine Bleeding (AUB), chronic pelvic pain and as an adjunct to estrogen therapy for patients needing long term treatment and desirous of uterus and/or future fertility. However, the LNG IUS is associated with the problem of spontaneous expulsion especially in patients having a large uterine volume, or distorted uterine cavity. The aim of this video article is to demonstrate a modified hysteroscopic suture fixation of LNG IUS in a patient with history of Mirena expulsion. A case of a 42-year-old woman, completed her family but not consenting to Hysterectomy, with a history of previous LNG IUS expulsion is presented. The procedure was performed within 25 mins, with minimal blood loss (<10ml) and the patient was followed up for one month, having no complaints with significant improvement in symptoms and showing LNG-IUS in position with no downward displacement.

Our case report demonstrates the feasibility and effectiveness of a modification of LNG-IUS suture fixation under hysteroscopy. It provides additional benefits such as ease of application, lesser instruments and resources needed and no need for a second hysteroscopy at the time of removal/ change of LNG IUS.

The LNG IUS is extensively utilized for both contraception and the therapeutic management of various gynecological conditions. It has demonstrated effectiveness in treating heavy menstrual bleeding, endometriosis, adenomyosis, and serves as an adjunct for endometrial protection in women undergoing estrogen therapy (1-4). The localized hormone release mechanism of the LNG IUS results in a lower systemic hormonal load, making it a favourable alternative to oral contraceptives, systemic hormonal treatments, and hysterectomy (5). However, spontaneous expulsion of the LNG IUS can occur, particularly in patients with uterine abnormalities, multiparity or heavy uterine bleeding (6-8). Expulsion reduces therapeutic efficacy and may lead to discomfort, unintended pregnancy, and increased costs due to re-insertion procedures (9). Ensuring optimal placement and stability of the device within the uterus is crucial for sustained effectiveness (10).

Various fixation techniques have been explored to address this issue, each presenting its own complexities (11). In this case report, a modified hysteroscopic suture fixation technique to secure the LNG IUS in patients prone to expulsion is described. This approach aims to provide a minimally invasive, cost-effective, and efficient solution.

A 42-year-old woman came with the complaints of severe dysmenorrhea and heavy menstrual bleeding, suspicion of adenomyosis. Ultrasound revealed a bulky uterus (9cm x 5cm x 4cm) with adenomyosis, the volume estimated ad ~180ml. She had two vaginal deliveries previously; her family completed and had undergone tubectomy. She was complaining of having heavy menstrual bleeding since many cycles and was chronically anaemic. However, the patient was not willing to have her uterus removed and wanted a long-term treatment with preservation of the uterus. She had a LNG IUS inserted once but at spontaneous expulsion occurred four months after insertion and the symptoms persisted. Hysteroscopic suture fixation of LNG IUS was discussed with the patient. The patient was informed about procedure. The procedure was performed under short general anesthesia. The cervix was dilated up to ten cm and the uterine cavity seen. The length of the cavity was around nine cm and endometrium was found to be thickened. The size of the hysteroscope used was 25Fr and instruments of the size 4mm in diameter were used with normal saline as distension media.

Using 5mm laparoscopic needle holder (passed into the cavity, parallel to the hysteroscope) and Ethibond 1 suture, a deep needle bite was taken in the posterior uterine wall. The vertical stem of LNG IUS was tied to the suture near the middle of one end and pulling onto the other end, the LNG IUS was positioned below the fundus and confirmed hysteroscopically. Both ends of the suture material were tied taut to the ING IUS thread just above the internal os and cut. Patient tolerated the procedure well.

The procedure was performed within 25 mins, with minimal blood loss (< 10 ml) and the patient was followed up for one month, having no complaints with significant improvement in symptoms and showing LNG-IUS in position with no downward displacement.

The levonorgestrel intrauterine system (LNG IUS) is widely recognized for its non-contraceptive benefits in managing various gynecological conditions, including adenomyosis and endometrial hyperplasia. These conditions often result in abnormal uterine bleeding, pelvic pain, subfertility and diminished quality of life. For women seeking fertility preservation or uterine-sparing treatments, the LNG IUS offers an effective long-term solution by significantly reducing uterine size, heavy menstrual bleeding, and dysmenorrhea. However, a notable challenge with LNG IUS usage is the risk of spontaneous expulsion, especially in patients with an enlarged uterine volume (greater than 150 ml). Studies have reported overall expulsion rates of approximately 9.6%, with higher rates observed in women with adenomyosis and myomas, ranging from 9.1% to 15.8% (12). One strategy to mitigate this issue involves pre-treatment with gonadotropin-releasing hormone (GnRH) agonists to reduce uterine size, thereby decreasing expulsion rates. However, long-term use of GnRH agonists is associated with adverse effects such as bone loss and menopausal symptoms, and may not be cost-effective.

Fixation of the LNG IUS presents a viable alternative, offering fewer side effects and reduced costs for women at high risk of expulsion who wish to preserve their uterus. Several studies have explored LNG IUS fixation techniques, including hystero-laparoscopic fixation and hysteroscopic suture fixation, with the choice of method depending on surgical expertise, available resources, and patient-specific factors. These techniques have demonstrated a significant reduction in expulsion rates.

In this context, we present a modified hysteroscopic suture fixation technique, building upon the method described by HaiHong Cui et al. (13). Our approach offers several advantages:

• Ease of Application: Traditional suture placement during hysteroscopy can be challenging due to the presence of fluid within the uterine cavity and limited space. Our modification simplifies the procedure, requiring a shorter learning curve and less extensive surgical training.
• Elimination of Additional Instruments: This technique does not necessitate the use of extra-corporeal knot-pushing devices, streamlining the procedure and reducing equipment needs.
• Eliminating the need for a second hysteroscopy at the time of removal of device.

These benefits position our modified technique as a practical and effective solution to the problem of LNG IUS expulsion, enhancing patient outcomes and procedural efficiency.

Our case report demonstrates the feasibility and effectiveness of a modification of LNG-IUS suture fixation under hysteroscopy. As compared to the procedure done previously, it provides additional benefits such as ease of application, lesser instruments and resources and no need for a second hysteroscopy at the time of removal/ change of LNG IUS. This method can have wider use due to shorter learning curve and better patient acceptability.