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Sir,

We are grateful for the reaction to our paper Pregnancy outcome after cervical conisation, a retrospective cohort study in the Leuven University Hospital.1,2 The limitations of our retrospective study and other published data are clearly discussed in the paper. As women with cervical intraepithelial neoplasia, stage 3 (CIN3) must be treated, the adverse effects on obstetrical outcome in future pregnancies will remain, whether the surgical intervention or factors related to the pathology, or both, are causal. I doubt if a proper randomised trial will ever be possible unless future therapeutical human papillomavirus (HPV) vaccines offer the opportunitiy to compare CIN3 treated medically with CIN3 treated with conisation or ablative therapy. Meanwhile, clinicians better adhere to approved management principles in cases with CIN3, and tailor the size of cones and the area of ablation to the lesion size and geography of the transformation zone in order to minimise the structural damage to the cervix. Obstetricians and their patients have to be aware of the possible adverse effects of a history of CIN3 and/or conisation on pregnancy outcome, especially preterm delivery. It remains unclear how to manage these women in subsequent pregnancies. Future studies should focus on the predictive value of cervical length measurements and the preventive effect of cerclage in cases with short or distended cervical canals.

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