We thank Gowri Dorairajan and Bhabani Pegu for their interest in our recent publication in the March 2019 issue.1 They suggest that the improvement in perinatal outcomes might not be attributable to pessary use alone, but also to the 45% compared with 36% difference in the elective cesarean delivery group. Indeed, it is our practice to advice women with twin pregnancies at 37 weeks of gestation or greater to undergo elective cesarean delivery.2,3 In our trial, 60% of women in the pessary group compared with 51.7% of women in the progesterone group were indicated to undergo elective cesarean delivery at 37 weeks of gestation or greater, but this difference is also a result of the pregnancy-prolonging effect. Pessary compared with vaginal progesterone for the prevention of preterm birth in women with twin pregnancies and cervical length less than 38 mm: a randomized controlled trial. [Extracted from the article]