We are grateful to Drs De Lima and van der Woude for their commentary on our recent meta-analysis.[1, 2] We fully agree with them that the minimal use of immunomodulators or antitumour necrosis factor (TNF) agents in pregnancy over the last 50 years would not be expected to make a major impact on the rates of remission in pregnant women during this time. However, many other features of IBD management, and pregnancy, have changed since the 1950s: monitoring of disease activity, the goal of deep remission, thresholds for escalation of therapy and maternal age at conception.
We suspect the fact that as only 2 of the 14 included studies occurred since 1990, the effect estimate in this meta-analysis is mostly a reflection of historical clinical management. Only the publication of high-quality studies from the current decade of IBD management will answer the question as to whether we are doing a better job of managing women in the preconception and pregnancy phases of life.