We read the article by Toh et al. 1 with great interest. The study concludes that cesarean scar ectopic pregnancy (CSP) may be managed both surgically and medically. At institutions where surgical expertise is unavailable, medical management would be valuable, with few adverse outcomes identified. However, as far as we know, the value of medical treatment of CSP still needs to be further explored.First, this study is a single-center retrospective study with a small sample, and without clear diagnostic criteria and classification for CSP, which is very important for the selection of CSP treatment strategy. 2 Second, there is currently a lack of recognized drug regimen for the medical treatment of CSP. The guidelines of the Society for Maternal-Fetal Medicine (SMFM) in 2022 suggest intragestational methotrexate (MTX) for the medical treatment of CSP, with or without other treatment modalities (GRADE 2C), and recommends that systemic MTX alone should not be used to treat CSP (GRADE 1C). 3 However, most of the patients in this study used systemic MTX.Third, as stated in meta-analysis and in the SMFM guidelines, surgical treatment should be the first-line treatment for CSP. 3,4 At present, there are many reported surgical treatment modalities, but operative resection (with transvaginal or laparoscopic approaches) should be considered for the surgical management of CSP, and sharp curettage alone should be avoided (GRADE 2C). 3 Compared with medical treatment, operative resection has the advantages of higher success rate, faster recovery, and shorter follow-up time. 3,4 However, of the six patients who were treated surgically in this study, two were treated with suction dilation and curettage, and two with laparotomy.Fourth, the initial treatment of CSP is very important. Improper initial treatment will complicate subsequent treatment. Because every CSP should receive appropriate initial treatment, we believe that for institutions that are not resourced for surgical treatment, patients should be referred promptly rather than receiving medical treatment. 3 Fifth, although there is little evidence of pregnancy outcomes after CSP treatment, the incidence of recurrent CSP (RCSP) is not as low as the author thinks. Our meta-analysis showed that the incidence of RCSP was 15.3%, and the incidence of spontaneous abortion in subsequent intrauterine pregnancy was 14.6%. 5 Therefore, effective contraception should be in place those who are not planning pregnancy, and supervision should be strengthened for those who have fertility requirements.The choice of CSP treatment should be personalized. Surgical treatment, rather than medical treatment, should be the first-line treatment for CSP. At institutions where surgical expertise is unavailable, timely referral of patients should be considered. For medical treatment of CSP, the specific drug regimen, indication, and impact on subsequent fertility need further research and exploration.
