Cervical Ectopic Pregnancy After Frozen Embryo Transfer: Methotrexate Failure Managed With Uterine Artery...

Cervical ectopic pregnancy is a rare but potentially life-threatening form of ectopic implantation that poses a significant risk for severe hemorrhage and loss of fertility. This case report describes a cervical ectopic pregnancy following frozen embryo transfer that failed multi-dose methotrexate therapy and was successfully managed with uterine artery embolization followed by ultrasound-guided dilation and curettage. A 37-year-old nulliparous woman with a history of bilateral salpingectomy and tubal factor infertility conceived after frozen embryo transfer. She received a multi-dose systemic methotrexate regimen consisting of four intramuscular doses over seven days with alternating oral leucovorin, followed by bilateral uterine artery embolization and immediate ultrasound-guided suction dilation and curettage. On Day 0, the patient presented with vaginal bleeding and was diagnosed with a cervical ectopic pregnancy at approximately six weeks' gestation. Initial β-hCG was >14,000 mIU/mL (reference value < 5 mIU/mL). She underwent multi-dose systemic methotrexate, but β-hCG declined only 13% by Day 2, 25% by Day 4, and then plateaued with <2% change between Day 4 and Day 6, consistent with methotrexate failure. She continued to experience persistent spotting. On Day 13, she underwent bilateral uterine artery embolization followed immediately by ultrasound-guided suction curettage. The procedure was uncomplicated, with minimal blood loss (5 mL) and no transfusion. Pathology confirmed gestational tissue, and she was discharged the same day with outpatient follow-up with her reproductive endocrinology and infertility physician. Cervical ectopic pregnancy is a rare but potentially catastrophic condition, particularly in the context of assisted reproductive technology. In this case, high β-hCG levels and prior embryonic cardiac activity predicted poor response to methotrexate. Fertility-preserving surgical strategies, specifically uterine artery embolization followed by suction curettage, provided safe, definitive management and avoided hysterectomy. This case highlights the importance of early recognition of methotrexate failure, prompt multidisciplinary coordination, and timely transition to fertility-preserving surgical intervention to optimize outcomes in patients with cervical ectopic pregnancy.