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Clomiphene Stair-Step Protocol for Women With Polycystic Ovary Syndrome.

In Reply: We thank Drs. Meller, Izbizky, and Otaño for their letter about recent article.1 We note also their 2014 letter describing their series of patients (Meller CH, Izbizky GH, Otaño L. Timing of delivery in placenta accreta [letter]. Am J Obstet Gynecol 2014;211:438–9), and we encourage them to publish this series in the peerreviewed literature. It is impossible to understand important aspects of their cases without a full examination of their data. Our population may well be different in that we have a much higher rate of increta–percreta cases than accreta cases than is normally seen given our referral population. In our article, we conclude that, “it may be reasonable to individualize scheduled cesarean hysterectomy at 33 weeks of gestation.”1 We did not suggest that this should be a policy and still do not suggest this. Many variables, including a history of vaginal bleeding, preterm uterine contractions, and the degree of invasion, may play into the individualized decisionmaking process. We agree that, with an individualized decision-making process under appropriate individualized circumstances, pregnancy in a patient with accreta can be allowed to continue up to 35– 36 weeks of gestation under close observation.