Comparative Impact of Medical, Surgical, and Expectant Management of Tubal Ectopic Pregnancy on Subsequent Fertility: A Network Meta Analysis

Abstract

Background: Ectopic pregnancy (EP) is a primary cause of maternal health issues and fatalities during the first trimester. With advancements in treatments such as methotrexate (MTX), salpingectomy, salpingostomy, and expectant management, the focus in clinical practice has shifted to enhancing future fertility outcomes and minimizing the risk of recurrence. Aim and Objective: This study sought to address the question: “How do medical, surgical, and expectant management strategies for tubal EP compare in terms of future fertility and recurrence rates?” Methods: An extensive search was conducted in PubMed, Embase, Cochrane Library, and Web of Science up to 2025. The studies considered were randomized controlled trials (RCTs) and cohort studies that compared MTX, salpingectomy, salpingostomy, or expectant management, and reported on intrauterine pregnancy (IUP), live birth, or recurrent EP. Data were analyzed using arm-level event rates, and a network meta-analysis was performed to facilitate both direct and indirect comparisons. Results: Ten studies (comprising two RCTs and eight cohort studies with follow-up periods ranging from 12 to 80 months) met the inclusion criteria. Fertility outcomes were generally similar across the different strategies. MTX demonstrated the highest absolute success rate (72.4%), while expectant management achieved the highest SUCRA ranking (100%) and showed the most consistent results. Salpingostomy was ranked lowest and was associated with a higher risk of recurrence (up to 14.3%). Conclusion: All major strategies maintain fertility potential, but salpingostomy is linked to a higher risk of recurrence. Expectant management shows promise for stable patients; further large RCTs are necessary to refine criteria for patient selection.