Unilateral Tubal Twin Ectopic Pregnancy: A Case Report of Failed Systemic Methotrexate Management Requiring Surgical Intervention

Background: Tubal twin ectopic pregnancy is extremely rare, with an incidence of 1:125,000 spontaneous pregnancies. We present a case of unilateral tubal twin pregnancy with fetal heartbeats that occurred in a patient submitted to in vitro fertilization. Case: A 26-year-old woman was referred to our hospital with increasing β-human chorionic gonadotropin (β-hCG) levels without an intrauterine gestation. The serum β-hCG level was 17,641 mIU/mL and ultrasound revealed two separate gestational sacs within the Lt. adnexa, each containing a live embryo. Due to stable vital signs and the small size of the gestational sacs, the patient was treated with methotrexate (MTX). Despite two courses of treatment with MTX, the therapy failed in the resolution of viable ectopic pregnancy. Conclusion: Therapy of MTX in cases of tubal twin ectopic pregnancy with fetal cardiac activity should be reconsidered.