We would like to thank the authors for presenting the classification description of anatomical variations in their patients and highlighting the fact that the degree of vaginal atresia can be negatively related to the patients’ sexual and psychological health. Regarding patient management, it is notable that in this cohort, approximately 50% of the patients remained untreated because they had not engaged in sexual intercourse (although some may question whether there may be a relationship between psychological consequences and difficulties with intercourse). Furthermore, no difficulties with sexual intercourse were noted in 41.7% of patients using either self-dilatation therapy or coital dilatation. Only a minority of patients (8.3%) underwent vaginal reconstruction.

Conservative management includes self-dilatation or Vecchietti vaginoplasty to generate progressive traction on the vaginal stump. Surgical formation of the neovagina using mucous/cutaneous, peritoneal, or ileal/sigmoid grafts or internal thigh fasciocutaneous cutaneous flaps is another approach [2]. We would also like to highlight that uterine transplantation can be offered to such patients as an option for uterine factor infertility [3]. Around thirty live births after uterine transplantation have been described to date [4].

Current recommendations emphasize dilatation therapy as the first-line treatment for vaginal agenesis and/or coital dilatation in patients who are able to regularly engage in sexual intercourse. Further studies investigating the criteria for surgical intervention and functional outcomes are needed to apply a safe, acceptable technique that can enable patients to engage in early sexual intercourse with a low incidence of shrinkage and a high rate of patient satisfaction.

We would like to thank the authors for sharing their valuable experience.