The article “Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study” describes the effectiveness of prepregnancy laparoscopic abdominal cerclage (LAC). Total fetal survival rate was reported to be 90%, which is similar to that of transabdominal cerclage. We believe that, without qualifiers, the success of the LAC procedure is inflated.

There are reports of high-cervical cerclage by approaches that include laparotomy, high-risk vaginal, laparoscopic, and robotically assisted. The latter 2 approaches are often performed before pregnancy. In each of these studies, success rates and patient populations are variably defined, which makes comparison difficult.

In the study by Burger et al, the total fetal survival rate was calculated by dividing 27 pregnancies that ended with a surviving baby by 30 pregnancies that continued past the first trimester (90%). Women who undergo high-cervical cerclage accept risk with the goal of producing a baby. We therefore propose that the appropriate measure of success is the number of surviving babies divided by the number of procedures performed, which in this cohort was 27 of 52 (52%). Although it is important to avoid attributing first-trimester losses to cerclage failure, other techniques for high-cervical cerclage are not performed until the second trimester. Thus, no such women undergo the procedure, but never successfully conceive.

Additionally, some women in the LAC cohort may not have been at highest risk for preterm birth. For example, loop electrocautery excision procedures may not be as compelling a risk factor for preterm birth as previously believed. Including women who are at lower risk for preterm birth may inflate the apparent success rate of the procedure. Proponents of minimally invasive techniques argue that reduced morbidity warrants its use in broader patient populations. However, exposing women to any risk when they have a low likelihood of preterm birth does not seem justified.

Minimally invasive approaches have lower operative morbidity and faster recovery. However, reduced morbidity is only beneficial if the minimally invasive procedures are as equally effective at preventing preterm birth as more invasive procedures in the same patient populations. Additionally, any advantage of performing procedures outside pregnancy must be balanced by the possibility that women may undergo the procedure, but never successfully conceive. By more consistently defining procedural success rates and comparing similar populations, the best therapy for these patients may be easier to elucidate.