Background: We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Methods: Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Main results: Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Conclusion: Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.