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Reply of the Authors:We are writing in reply to the comments raised by Dr. Sentilhes on our recently published article (1). We much appreciate the remarks made by a team who have been working on surgical treatment to control severe postpartum hemorrhage and especially on uterinesparing procedures (2, 3). Our purpose was mostly to highlight the potential mid-and long-term effects of uterine compression sutures on fertility.Regarding vessel ligation procedures, we agree with the investigators on their analysis of the literature on the slightest impact on fertility (4-7). We also believe that we should start with uterine artery ligation, which is much easier to perform.But, concerning the stepwise devascularization (8), our thinking is quite different. This surgical process must absolutely be differentiated from Tsirulnikov's triple ligation (9) or hypogastric artery ligation. The Tsirulnikov procedure (9) combines uterine artery ligation, round ligament ligation, and utero-ovarian ligament ligation, preserving ovarian vascularization by the integrity of the suspensory ligament of the ovary.In stepwise devascularization, as describe by AdbRabbo (8), ovarian vascularization is interrupted by ligation: uterine artery and suspensory ligament of ovary. No studies have evaluated ovarian function by anti-M€ ullerian hormone plasma level or antral follicle count by ultrasound after this type of procedure, which, if anatomy was not to change, leads to ovarian ischemia. In addition, in a study by Sentilhes et al. (6), 2 of 12 patients (17%) had menopausal status after treatment by stepwise devascularization, as regularly described from AbdRabbo (8) (uterine artery ligation and suspensory ligament of ovary ligation). Therefore, in our practice, we use the Tsirulnikov (9) procedure in the first attempt. In case of failure, we prefer hypogastric artery ligation to stepwise devascularization, because it preserves ovarian vascularization by the integrity of the suspensory ligament of ovary.Finally, we try uterine compression sutures, therefore if hemostatic hysterectomy is needed, ovarian function will still be preserved.

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