Reviewer’s report
Title: 
An innovative surgical approach: Suture fixation of the levonorgestrel-
releasing intrauterine system in the treatment of adenomyosis
Version: 
2 
Date: 
19 Apr 2022
Reviewer's report:
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Thank you for considering the comments and for your reply. There remain
however some aspects of the manuscript that fall short. You included the uterine
dimension in the response to referee but claim that this critical information was
not included in the rather long manuscript for the sake of brevity. The data
provided suggest that about half of the women might have been eligible for a
Mirena insertion without the additional burden of an operative intervention. I
note that your published video states that the case required 30 minutes and an
overnight hospital stay. This is a significant burden both in terms of risk and
expense. The abstract still refers to Mirena as a "ring", which it is not. The
description of the technique as minimally invasive is not supported given that it
substitutes a less invasive option. The technique as presented includes 1
expulsion and 2 displacements out of 12 cases. This is significant in terms of
patient management including additional contraception use and efficacy.
Adenomyosis does NOT distort the uterine cavity unless it is a rare adenomyotic
polyp. It is curious that the inclusion criteria considered an enlarged uterus as
'preferred' not as 'essential'. 52mg 20ug/25 h (add definition). The HCSS cannot
have a 25-Fr working channel as that is the overall size of the hysteroscope. Do
you mean laparoscopic of hysteroscopic surgical instruments? Hysteroscopy is a
poor method of addressing endometrial thickening in premenopausal women.
Discussion: what is meant by mental illness?
lifelong plan is not needs as the symptoms resolve into the menopause.
references to endometrial cancer should be removed the information provided is
both inaccurate and redundant. It is hardly plausible that the intervention
proposed is a lower cost. You refer to a 10-15 minute procedure. This is highly
unlikely if the total theatre occupancy time it considered. LNG was expelled in
one case and displaced in two. This is not extremely low and likely to be
comparable to that in women with uteri at the upper limit of FDA approved
usage. The reference to the 'improved fixation at end of the discussion is
redundant as it does not address the cases presented in the manuscript. The
Legends are not presented in an acceptable format. Figures 2-4 can easily be
replaced by a few sentences.
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