High-intensity focused ultrasound ablation combined with systemic methotrexate treatment of intramural ectopic pregnancy: A case report

Rationale: Intramural ectopic pregnancy (IMP) is a rare ectopic pregnancy with an unclear etiology, and standard treatment guidelines currently remain unclear. The main treatment option is local excision of IMP via laparoscopy or laparotomy. Patient concerns: A 32-year-old woman with adenomyosis presented with amenorrhea for 7 weeks and a serum beta-human chorionic gonadotropin (HCG) level of 6882 IU/L. The patient had a history of laparotomy for adenomyosis 5 years previously. Three-dimensional ultrasonography showed a live gestational sac (GS) of 9 x 15 x 18 mm located in the left posterior wall of the uterus and a sinus tract connecting the sac and the endometrial cavity. MRI revealed the GS located in the adenomyosis and a 1.0-cm sinus tract connecting the GS and the endometrial cavity. Diagnoses: IMP with adenomyosis. Interventions: High-intensity focused ultrasound (HIFU) treatment combined with systemic methotrexate (MTX) was performed to treat IMP, which would avoid operation and massive bleeding. Outcomes: Serum beta-HCG levels decreased to normal 4 weeks after HIFU treatment and the GS was not found on MRI after 4 months. The sinus tract was significantly shortened after the HIFU treatment. Lessons: HIFU ablation combined with systemic MTX is effective for the treatment of IMP and is favorable for maintaining fertility.