Successful fertility-preserving management using systemic methotrexate and laparoscopic resection of intramural pregnancy following in vitro fertilization and embryo transfer: a case report

Intramural pregnancy (IMP) is the rarest form of ectopic pregnancy and lacks an established protocol for its definitive diagnosis and treatment. Its diagnosis remains challenging, as clinicians are often unfamiliar with this condition. Early diagnosis and treatment are crucial to minimize the risk of uterine rupture and to preserve reproductive potential. This report describes the case of a 39-year-old woman (gravida 4, para 0) with a history of repeated dilatation and curettage who developed an intramural ectopic pregnancy following in vitro fertilization and embryo transfer. Initial ultrasound examination revealed an empty gestational sac within the uterine cavity, which was diagnosed as an intrauterine missed abortion. Following an unsuccessful attempt at surgical evacuation, magnetic resonance imaging (MRI) confirmed the diagnosis of IMP. Systemic methotrexate in multiple doses resulted in a gradual decline in serum β-human chorionic gonadotropin (β-hCG) and reduced vascularity on ultrasound. Despite this response, the conceptus persisted, and laparoscopic excision was performed, leading to complete resolution. The patient was discharged 3 days after surgery without complications and was able to resume infertility treatment 3 months postoperatively. This case highlights the effectiveness of a staged therapeutic strategy combining systemic methotrexate and laparoscopic surgery to achieve complete resolution while preserving reproductive potential. This report provides practical insights into optimizing the timing of surgical intervention for fertility-preserving management in this rare and challenging condition. • Intramural pregnancy after in vitro fertilization and embryo transfer was diagnosed using Doppler ultrasonography and pelvic magnetic resonance imaging. • A staged approach using systemic methotrexate followed by laparoscopic surgery was effective. • Preoperative methotrexate reduced vascularity and enabled safe, fertility-preserving surgery. • Integration of imaging findings with β-hCG trends was crucial for clinical decision-making. • This case provides practical guidance for managing intramural pregnancy after in vitro fertilization and embryo transfer.