We appreciate the comments offered by Dr Esmyot et al., stating that our research findings raise important issues that need to be addressed by studies that are specifically designed to determine the effects of cervical surgery on future fertility. As noted in our discussion, although our study is not without its limitations, it is the most rigorous study published to date to evaluate the association between surgery for cervical intraepithelial neoplasia (CIN) and subfertility.
Our finding of a significantly delayed time to conception is not likely to be biased for three reasons: (1) the results were confirmed within two different control groups (colposcopy only; no colposcopy and no cervical surgery); (2) treated women were provided with a 4-week ‘handicap’ in the calculation of their time to pregnancy to account for post-surgical healing time; and (3) risk estimates were consistent within our three study population subgroups (i.e. preterm delivery cases, small-for-gestational-age cases and normally grown, term controls).
Importantly, as this paper went to press, new consensus recommendations were issued from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology calling for the revision of the terminology for human papillomavirus-associated squamous lesions of the lower anogenital tract, from a three-tiered system (i.e. CIN 1, 2 and 3) to a two-tiered system [i.e. low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL)]. Once implemented, these changes could increase the number of cervical surgeries in the USA.
We join Dr Esmyot et al. in their recognition of the need for further investigation into the potential impact of cervical surgery on the risk of subfertility.