Background: Surgical management is curative for tubal ectopic pregnancy (TEP), but multiple studies documented the safety and efficacy of single-dose methotrexate (SD-MTX) as a medical treatment.  Objectives: Evaluation of the success rate (SR) of letrozole (LTZ; 5 mg/day) for 4-day versus SD-MTX (50 mg/m²) as medical treatment of TEP as judged by the rate of shift-to-surgery. Patients and Methods: Serum βhCG levels were estimated on D1, 4, 7, 11 and 18 of start of therapies and the extent of change (Δ βhCG) was calculated concerning D-1 levels. For patients of LTZ group, if Δ1-4 βhCG was >10% LTZ therapy was continued, but if it was <10% without TEP disruption, SD-MTX injection was given or salpingectomy was undertaken if TEP was disrupted. Success was defined as TEP resolution as documented by TVU and serum βhCG <15 IU/L within about 19 days of therapy. Results: SR was significantly higher with LTZ or LTZ/MTX than with SD-MTX and Δ1-4 βhCG was significantly higher with TLZ alone than MTX alone and with MTX alone than the total of LTZ/MTX group. The Δ1-7 βhCG was significantly lower with MTX alone than LTZ alone or LTZ/MTX. Statistical analyses defined age and Δ1-4βhCG as significant predictors for high SR. Conclusion: Medical treatment for TEP is feasible with SR of 86%; 4-day therapy of LTZ alone provided SR of 62% and 90.6% if supplemented by SD-MTX. The applied policy of using LTZ as a medical treatment for TEP significantly spared the need for MTX and surgery.