We appreciate the comments of Drs Salmeen and Parer regarding our recent article.

First, Drs Salmeen and Parer have concerns on the fetal survival rate calculation that we used. We agree that, in the most ideal situation, it should be calculated by the total number of surviving infants divided by the total number of patients who received a laparoscopic abdominal cerclage (LAC). However, not all patients tried to conceive immediately after placement; some patients postponed their attempts to conceive or their eventual fertility treatment for varying reasons. In addition, the follow-up period was not long enough for all patients to conceive. Therefore, it does not seem to be appropriate to include these patients in the fetal survival calculation or to draw any solid conclusions on potential fertility problems in these patients. Thus, we decided to base the fetal survival rate on pregnant patients only.

Second, Drs Salmeen and Parer pointed out that not all included patients were at high risk for preterm birth. The authors agree that the risk for premature birth is highly dependent on the indication for LAC placement. We are aware that patients with ≥1 failed vaginal cerclages in particular are the group with the highest risk. This is exactly the reason that we presented our results for the group with a previous failed vaginal cerclage and the group with placement because of extensive previous cervical surgery (recurrent loop electrosurgical excision procedure or conization of the cervix or trachelectomy) separately. We did underline that it is not necessary to place an LAC in all patients with previous extensive cervical surgery. Additional studies are obligatory to study the need of an abdominal cerclage in this patient group.

Third, Drs Salmeen and Parer suggest the placement of a cerclage in the second trimester of pregnancy to reduce the risk of placement in patients who do not conceive or who experience a failure of the first pregnancy after LAC. However, a recent systematic review on this topic demonstrated that placement in pregnancy was associated with less favorable outcomes. Moreover, the results of laparoscopic placement on pregnancy outcomes seemed at least comparable with the laparotomic approach. Based on these results, we consider LAC placement as an effective treatment that might be considered in a selected patient group who are at risk for premature delivery, in particular in patients with previous failed vaginal cerclages. However, we do underline the lack of straight-forward comparison in randomized controlled trials of the laparoscopic vs the laparotomic approach and placement before (interval) vs placement during pregnancy. Furthermore, we fully agree with Drs Salmeen and Parer that standardized indications for the insertion of a LAC and correct registration of risk factors are necessary to improve our care for these patients.