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I thank you and Dr Yang for your encouraging interest in my manuscript which is entitled “Systematic review: What is the best first-line approach for cesarean section ectopic pregnancy?” [1] As Dr Yang has most kindly specified, our manuscript brings forward interventional methods such as hysteroscopic and laparoscopic hysterotomy rather thanmedical methods for the treatment of cesarean scar pregnancy (CSP). Dr Yang has objected to a result of our manuscript which argues that uterine artery embolization (UAE) has a low success rate and a high complication rate as a first-line approach for CSP. Dr Yang has also hypothesized that several factors may be responsible for this argument about UAE. The first factor is not applying strict criteria for screening the CSP cases that have been delineated in literature. It is true that a number of case reports have been included in our systematic review but it should be understood that CSP is a relatively new medical term and these case reports are valuable as the first scientific descriptions for the diagnosis and treatment of CSP. As cesarean deliveries have gradually increased in number, CSP has become more frequent and cases of CSP have accumulated to reach a number which is required publish a case series or clinical study. These publications have usually focused on the success of a certain treatment method which has been adopted by a certain study center. We have presumed that specifically indicating the success of a certain treatment method by describing a series of cases and maybe not mentioning the failure of individual cases would also cause a selection bias. For this reason individual case reports have been considered as independent trials for the diagnosis and treatment of CSP prior to the establishment of management methods for this clinical entity. Moreover, Dr Yang has contravened our methodology whereby the efficiency of a therapeutic option is assessed by whether this option leads to a high complication rate and whether the patients treated with this option need a secondary treatment. It has been argued that the failure rate of a treatment method may be high but the hysterectomy rate may be low because treatment methods may be combined. However, this manuscript seeks the best firstline approach for the treatment of CSP instead of looking for the best combined treatment. In other words, the aim of our research has been to define the treatment method which would achieve the highest success rate with the lowest complication rate at the first step. The absence of any requirement for any complementary treatment and the lack of any need for urgent treatment would surely provide a superior therapeutic option.

Response to “The first-line approach for cesarean scar pregnancy: The most adopted being not the best”