This 32 y/o female presented with right sided lower abdominal and pelvic pain and a positive pregnancy test. She was being treated for infertility. Selected images from a transvaginal sonogram are shown above. They demonstrate a combined (heterotopic) pregnancy, with an ectopic tubal gestational sac and an intrauterine gestational sac. The tubal pregnancy was confirmed at laparotomy. The possibility of heterotopic pregnancy is more likely to occur in population groups with a high incidence of pelvic infections and in patients who receive ovulation-induction medication. The diagnosis of this rare condition may be difficult and careful ultrasound examination is mandatory. Lower abdominal/pelvic pain in uncomplicated intrauterine pregnancy is a common symptom. Diligent ultrasound examination of the adnexal regions is important so as not to overlook the rare combined intrauterine and extrauterine pregnancy.