Reviewer’s report
Title: 
An innovative surgical approach: Suture fixation of the levonorgestrel-
releasing intrauterine system in the treatment of adenomyosis
Version: 
1 
Date: 
17 Mar 2022
Reviewer's report:
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The authors report on the outcome of 12 patients with adenomyosis who had a
Mirena device inserted and sutured inside the uterus using an operative
hysteroscope.
The study assessed the menstrual outcome and pain scores for this cohort
comparing pre-operative and post-operative scores.
The following points need to be addressed:
1- The intro and abstract: please correct: Nonetheless, but/accompanied/ the
ring? (Mirena is not a ring)/ annoying problem/ sew (you mean suture). 
2- The claim is made that this technique (perfectly solves..). in reality, there was
one expulsion and two misplacements which suggests that the outcome is less
than perfect.
3- It is perhaps true that the technique is "minimally invasive" as it involves
hysteroscopic surgery. Nevertheless, it should be acknowledged that the
technique involves considerable burden and cost compared to the standard
insertion of the Mirena device. It does not PREVENT the risk of expulsion and it
remains an open question as to whether it reduces the rate of expulsion.
4- The rate of expulsion compared to standard IUS insertion cannot be
determined with confidence based on this limited cohort.
5- Please provide a reference to the claim that LUG-IUS is the most promising
medical therapy (IN THIS COHORT) - given that studies of IUS in adenomyosis
have tended to exclude women with enlarged uterus and to impose limits on
uterine size.
6- Line 32: adenomyosis does not distort the cavity.
7- Line 34-36: what is your justification for the claim.
8- Line 53: supine lithotomy: is lithotomy not supine.
9- What is Endometrial condition? What does ..etc refer to? How many patients
were excluded by these exclusion criteria?
10- Throughout the test, the tense needs to be corrected to conform with standard
medical literature.
11- Results: Project: you mean study.
12- The numbers are very small, please remove the percentages and provide the
number of patients 3, 4 and 5.
13- What was the exact sizes of the uterine cavities, and what were the patient
characteristics?
14- The following pictures vividly describes..: what pictures? What is vivid?
15- One of whom underwent hot flush either. Please correct.
16- When 4 complained of prolonged spotting, 3 had abnormal discharge, one
expulsion and 2 displacements: this suggests that contrary to the claim made, the
outcome was less than perfect.
17- The authors state that they came up with an improvement plan. This in effect
used a nonabsorbable suture to anchor the IUS, but there are no results provided
and indication as to complication rates or how the device may be removed later.
18- Discussion: Massive bleeding is not a term commonly used outside
pregnancy.
19- Reference is made to expulsion as a factor that affects patient decision
making, but the need for operative anchoring itself is an important factor. The
authors do not provide an account of the surgical time, anaesthesia or intra-
operative features of the intervention.
20- Reference is made to the healthcare resources: what are the resource
implications of this intervention?
21- The claim around fewer side effects and lower expense are not substantiated
from this study.
22- Please correct: the most worth mentioning. One expulsion and two
displacements is not extremely low.
23- Please correct: it was firmly and would be no expulsion - video for the
majority of gynecologists to learn and communicate.
24- Please rephrase: and here we have some experience to share.
25- What was the operative time? How many sutures did tear through the tissue?
26- Please rephrase: sending the needly into the uterine cavity.
27- We will continue to popularize: please remove.
28- Figure legends: please follow standard conventions.
29- Figure 2 and 3 are provided as pictures.
30- Figure 4: can easily be replaced with text. What are the decimal points?
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Is the study design appropriate to answer the research question (including the use
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presented?
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