Introduction LNG-IUD although used extensively for its non-contraceptive indications like abnormal uterine bleeding (AUB), dysmenorrhoea and fibroid uterus, one of the major drawbacks is the high expulsion rates, especially among adenomyotic and fibroid uterus.
Material and Methods Altius Hospitals, Bangalore have developed a new technique of LNG-IUD fixation, which employs hystero-laparoscopy and usage of a long port closure needle with delayed absorbable sutures.
Conclusion. It ensures proper placement and fixation of the LNG-IUD to the uterine cavity, reduces the expulsion rates and has the advantages of being a day care procedure.
Keywords : Abnormal uterine bleeding · Dysmenorrhoea · Intrauterine device expulsion · LNG-IUD · Hystero-laparoscopic fixation
Levonorgestrel-releasing intra uterine device (LNG-IUD)
has been widely used for its non-contraceptive usage over
the years. Its use for dysmenorrhoea and AUB is well known
among Gynaecologists. LNG-IUD is equal or superior to
treatment with systemic progestins or oral contraceptives
in adolescent and menopausal women for dysmenorrhoea
[1]. It also significantly reduces size of uterus, menorrhagia
and dysmenorrhoea in adenomyotic uterus [2]. One of
the common problems with its usage is the high expulsion rate, 9.6% overall and a higher rate (9.1–15.8%) in women
with adenomyosis and myomas [3]. Even women with heavy
menstrual bleeding and dysmenorrhoea have a higher expulsion
rate than women with normal uterus [3]. The expulsion
rates were similar among nulligravida and parous women
[1]. Considering this gynaecologists are finding ways of providing
the benefits of LNG-IUD without the risk of expulsion,
for women who are desirous of saving the uterus and
avoiding extensive surgeries [4].
To introduce an effective technique using hystero-laparoscopy for suture fixation of LNG-IUD in patients with AUB and history of LNG-IUD expulsion or where risk of expulsion of LNG-IUD is high.
A 34-year-old woman diagnosed with adenomyosis had endured 1 year of severe dysmenorrhea and 5–6 months of heavy menstrual bleeding. She gave history of preterm birth with cervical incompetence and spontaneous LNGIUD expulsion in the 1st month of insertion. Transvaginal ultrasonography revealed enlarged uterus with adenomyosis. She wanted her heavy menstrual bleeding and dysmenorrhoea to be relieved and insisted on preserving uterus and menstrual function.
InterventionAn informed consent was obtained from the patient. Firstly, diagnostic hysteroscopy was done, and the uterine cavity was found to be bulky and adenomyotic (honeycomb pattern) with no other local pathology. Serial cervical dilatation was done up to Hegar’s No. 8 to facilitate negotiation of port closure needle. Laparoscopy was performed with two contralateral secondary ports for laparoscopic securing of knots. LNG-IUD was prepared by tying a PDS suture at the neck with both free ends of the suture cut to 20 cm length (Fig. 1). Free end of the PDS was held with long port closure needle and introduced through cervix, uterine cavity and pierced through full thickness of uterine wall (Fig. 2). It was then held with plain graspers laparoscopically and port closure needle was withdrawn. The other free end of suture was introduced 2–3 cm away from the first suture end in a similar fashion. The two ends were then pulled laparoscopically with graspers at equal distance simultaneously, to place the LNG-IUD at fundus of uterus. Fixation of LNG-IUD was achieved by placing 5–6 knots intracorporeally on the fundus (Fig. 3). After confirming haemostasis laparoscopically, a relook hysteroscopy was performed to confirm proper position of the LNG-IUD inside cavity.
The LNG-IUD was fixed successfully within 30 min at the fundus in the uterine cavity by hystero-laparoscopy using PDS suture. The intraoperative blood loss was < 5 mL, and patient was discharged after 12 h of observation with no postoperative complications. At 6 months and 1 year followup, symptoms were significantly reduced, and ultrasound demonstrated normal position of the LNG-IUD without displacement or expulsion. The author has successfully implemented this technique in two other cases with similar success rates.
Adenomyosis and fibroid uterus affect women of reproductive
age and are often associated with AUB and dysmenorrhoea.
In the present day and age with the advent of
various medical and minimally invasive treatment options,
with most women postponing the age of pregnancy, it is
common to come across women opting for a medical treatment
over an extensive surgical treatment/hysterectomy for
these conditions. LNG-IUD being a hormonal contraceptive
is also popular for its non-hormonal uses in conditions like
AUB, adenomyosis, endometrial hyperplasia, endometriosis,
and dysmenorrhoea [5] Spontaneous expulsion is a common
drawback of LNG-IUD with crude expulsion rates of
9.6% and an even higher rate of up to 11.1% in adenomyosis,
15.8% in fibroid uterus, 13.4% with heavy menstrual
bleeding, 10% in dysmenorrhoea and 17.3% in women with
history of gonadotropin releasing hormone treatment pre
insertion has been reported in the past [3].
To combat this drawback, attempts have been made
to achieve a proper fixation and non-displacement of the LNG-IUD, with complete hysteroscopic approach using a
modified LNG-IUD [4]. Here at Altius Hospitals, Bangalore,
a novel technique has been employed for LNG-IUD fixation,
which involves a procedure as described above. We believe
this will allow for a definitive fixation of LNG-IUD with
reduced to almost nil expulsions.
Conflict of interest None.
Ethical Approval The work described has not been published before
and that it is not under consideration for publication anywhere else.
The publication has been approved by all co-authors, as well as by the
responsible authorities at Altius Hospitals, Bangalore. A case report for
IRB purposes is a retrospective analysis of one, two, or three clinical
cases. Therefore it does not have to be reviewed by an IRB.
Informed consent An informed consent was obtained from the patient for the surgical procedure and recordings. None of the above data/ figures reveals any patient identifiers. The Institutional Review Board does not mandate approval for case reports such as this, thus this report meets the Ethical standards as stated in the 1964 Declaration of Helsinki and its subsequent amendments.
