We thank Drs Larrañaga-Azcárate et al for their interest in our publication “Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation.” The main goal of our retrospective cohort was to evaluate whether the use of physical examination-indicated cerclage (PEIC) placement in twin pregnancies with asymptomatic cervical dilation of ≥1 cm before 24 weeks of gestation decreased the incidence of spontaneous preterm birth (SPTB) at different gestational ages and improved the neonatal outcomes when compared with expectant management. All women received McDonald cerclage in the treatment group; other differences in the surgical technique were not evaluated. The planned randomized clinical trial (RCT) on PEIC in women with twin pregnancies ( ClinicalTrials.gov ID#: NCT02490384 ) will evaluate whether cerclage will decrease SPTB and/or improve neonatal outcome but will not assess the PEIC technique either, because it was left up to the physician in charge of each case.

Most of current information about cerclage pertains to singleton pregnancies. Currently, there is limited evidence that 1 technique is superior to the other. We do agree with Drs Larrañaga-Azcárate et al that evaluating different techniques for cerclage is important. We did not identify an RCT that compared McDonald vs Shirodkar’s technique or any of the intraoperative PEIC techniques to decrease intraoperative rupture of membranes (eg, Trendelenburg, amnioreduction, retro-filled bladder, or pushing the membranes with a Foley balloon or sponge). Cervical occlusion was evaluated in an RCT, in which the addition (or not) of this technique was evaluated for either McDonald or Shirodkar cerclage for women with short cervix or dilated cervix. No differences in SPTB at different gestational ages, neonatal admission to the intensive care unit, or neonatal survival at discharge were seen when we compared cervical occlusion vs no cervical occlusion groups.

Perhaps the most important surgical technical aspect for cerclage is to place it as high as possible. In a retrospective cohort, postoperative transvaginal cervical length of >18 mm from stitch to external os has shown less SPTB at <32 weeks of gestation, and several other studies have confirmed that the higher the cerclage is placed, the less the incidence of SPTB.

Regarding nonsurgical aspects of cerclage, perhaps the most interesting is whether progesterone, indomethacin, or antibiotic use (or combinations of these 3 interventions) at the time of procedure improves outcomes.

Much research on cerclage, including for twin pregnancy, is still needed. Once cerclage will be evaluated in dedicated RCTs and proved safe and beneficial in twin pregnancy, we must evaluate other adjuvant therapies.