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Hi,
A decidual reaction alone is not enough to confirm intrauterine pregnancy and exclude a pregnancy of an unknown location.
The yolk sac is the first intrauterine structure to be visualised on ultrasound and so is a good indication that the pregnancy is intrauterine.
However, heterotopic pregnancies can occur and so the best way to exclude a PUL is to identify an embryo within a gestational sac
Please see:
https://www.isuog.org/static/uploaded/bb90c8fe-3b24-4318-8d1ae9bf49418431.pdf
https://www.isuog.org/static/uploaded/4daa1ea7-bc64-4c24-b81b17df5a684a38.pdf