{"paper_id":"bc3816be-0b9f-4cf1-b6d6-678a329ec7ce","body_text":"Top 10 priorities for future ectopic \npregnancy research: an international \nconsensus development study\nTara Ajith, M.B.B.S. (Hons),\na , b\nKurt T. Barnhart, M.D.,\nc\nRuth Bender Atik, B.A. (Hons),\nd\nTom Bourne, Ph.D.,\ne , f\nKrystle Chong, M.B.B.S. (Hons),\ng\nGeorge Condous, M.D.,\nh\nPamela I. Causa Andrieu, M.D.,\ni\nGrigorios Derdelis, Ph.D.,\nj\nAndrew W. Horne, Ph.D.,\nk\nJudith A. F. Huirne, Ph.D.,\nl , m\nDavor Jurkovic, Ph.D.,\nb\nEmma Kirk, M.D.,\na\nErnest H. Y. Ng, M.D.,\nn , o\nRicardo F. Savaris, Ph.D.,\np\nJanneke van’t Hooft, Ph.D.,\nl , m\nMadelon van Wely, Ph.D.,\nm , q\nLiesl de Waard, M.M.E.D.,\nr\nMaria P. Velez, Ph.D.,\ns\nJian Zhang, Ph.D.,\nt , u\nJames M. N. Duffy, D.Phil.,\nv\nMaria Memtsa, Ph.D.,\na , b\nMunira Oza, L.L.B.,\nw\nand Ben W. Mol, Ph.D.,\ng , q\nand the \nPriority Setting Partnership for Ectopic Pregnancy\na \nEarly Pregnancy and Acute Gynaecology Unit, Women's and Children's Division, Royal Free London NHS Foundation \nTrust, Royal Free Hospital, London, United Kingdom; \nb \nElizabeth Garrett Anderson Institute for Women's Health, \nFaculty of Population Health Sciences, University College London, London, United Kingdom; \nc \nDivision of Reproductive \nEndocrinology and Infertility, University of Pennsylvania, Philadelphia, Pennsylvania; \nd \nThe Miscarriage Association, \nRegistered Charity Number 1076829 (England & Wales) SC039790 (Scotland), Wakefield, United Kingdom; \ne \nEarly \nPregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea \nHospital, Imperial College London, London, United Kingdom; \nf \nDepartment of Development and Regeneration, KU \nLeuven, Leuven, Belgium; \ng \nDepartment of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, \nAustralia; \nh \nEndometriosis Ultrasound and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School, \nSydney, New South Wales, Australia; \ni \nDepartment of Radiology, Mayo Clinic, Rochester, Minnesota; \nj \nDepartment of \nObstetrics and Gynecology, Mitera Hospital, Athens, Greece; \nk \nMRC Centre for Reproductive Health, Institute for \nRegeneration and Repair, University of Edinburgh, Edinburgh, Scotland, United Kingdom; \nl \nDepartment of Obstetrics \nand Gynecology, Amsterdam University Medical Centre, Amsterdam, The Netherlands; \nm \nAmsterdam Reproduction & \nDevelopment Institute, Amsterdam University Medical Centre, Amsterdam, The Netherlands; \nn \nDepartment of \nObstetrics and Gynecology, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong; \no \nDepartment of Obstetrics and Gynecology, Queen Mary Hospital, Hong Kong, Hong Kong; \np \nDepartment of OBGYN, \nSchool of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; \nq \nCenter for Reproductive \nMedicine, Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands; \nr \nDepartment of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape \nTown, South Africa; \ns \nDivision of Reproductive Endocrinology and Infertility, Department of Obstetrics and \nGynecology, McGill University Health Centre, Montreal, Quebec, Canada; \nt \nDepartment of Obstetrics and Gynecology, \nInternational Peace Maternity and Child Health Hospital, Shanghai, People's Republic of China; \nu \nDepartment of \nObstetrics and Gynaecology, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China; \nv \nCentre for Reproductive Medicine, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom; and \nw \nThe Ectopic Pregnancy Trust, London, Registered Charity Number 1071811 (England and Wales) SC053187 (Scotland), \nLondon, United Kingdom\nObjective: To determine the future priorities for ectopic pregnancy research.\nDesign: Potential research questions were collated from an initial international survey, a systematic review of clinical practice guide -\nlines, and Cochrane systematic reviews. A rationalized list of confirmed research uncertainties was prioritized in an interim interna -\ntional survey. Prioritized research uncertainties were discussed during a consensus development meeting. Using a formal consensus \ndevelopment method, the modified nominal group technique, diverse stakeholders identified the top 10 research priorities for future \nectopic pregnancy research.\nSubjects: Healthcare professionals, people with lived experience of ectopic pregnancy, and others were brought together in an open \nand transparent process using formal consensus methods advocated by the James Lind Alliance.\nExposure: Not applicable.\nMain Outcome Measures: Top 10 research priorities for ectopic pregnancy.\nReceived June 17, 2025; revised September 22, 2025; accepted September 23, 2025.\nSupported by the Ectopic Pregnancy Trust, 483 Green Lanes, London, N13 4BS, United Kingdom\nData regarding any of the subjects in the study have not been previously published unless specified. Data will be made available to the editors of the jour -\nnal pre and/or post publication for review or query upon request. The appropriate checklist for this study design was followed.\nCorrespondence: Tara Ajith, MBBS (Hons), Royal Free London NHS Foundation Trust, Pond Street, Rosslyn Hill, London, NW3 2QG, United Kingdom (E-mail: \nTara.ajith@nhs.net ).\nFertil Steril® Vol. ■ , No. ■ , ■ 2025 0015-0282\nCopyright ©2025 The Authors. Published by Elsevier Inc. on behalf of the American Society for Reproductive Medicine. This is an open access article under \nthe CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).\nhttps://doi.org/10.1016/j.fertnstert.2025.09.032\nVOL. ■ NO. ■ / ■ 2025 1 \n\n\nResults: The initial survey was completed by 855 participants from 35 countries, and 1,220 potential research questions were sub -\nmitted. Three clinical practice guidelines and 43 Cochrane systematic reviews identified a further 24 potential research questions. A \nrationalized list of 49 confirmed research uncertainties was entered into an interim prioritization survey completed by 413 respon -\ndents from 20 countries. The top 10 research priorities were identified during a consensus development meeting involving 37 partic -\nipants from 10 countries. These research priorities are diverse and seek answers to questions regarding prevention, treatment, and the \nlonger-term impact of ectopic pregnancy.\nConclusion: We anticipate that the identified research priorities, developed to specifically highlight the most pressing clinical needs \nas perceived by healthcare professionals, people with lived experience of ectopic pregnancy, and others, will help research funding \norganizations and researchers to develop their future research agenda. (Fertil Steril\n®\n2025; ■ : ■ – ■ . © 2025 by American Society \nfor Reproductive Medicine.)\nKey Words: Ectopic pregnancy, research priorities, reproductive medicine, consensus science methods, modified Delphi method\nA\nn ectopic pregnancy is a potentially life-threatening \ncondition where a pregnancy implants abnormally \nto a site other than within the uterine endometrial \ncavity ( 1 ). They most commonly occur within the fallopian \ntubes (95%) but may also be present in other sites such as \nthe ovary (1.14%–3.12%), abdominal cavity (1%), or cervix \n(0.4%) ( 2 , 3 ). Ectopic pregnancies affect between 1% and \n2% of all pregnancies ( 4 ). The global incidence of ectopic \npregnancy varies widely, influenced by factors such as access \nto healthcare; prevalence of risk factors, including pelvic in -\nflammatory disease; assisted reproductive technologies; pre -\nvious gynecological surgery; and sociodemographic \nconsiderations ( 5–8 ).\nManagement of ectopic pregnancy has evolved signifi -\ncantly, encompassing expectant, medical, and surgical ap -\nproaches. Expectant management, although less commonly \nemployed, may be appropriate in selected cases where spon -\ntaneous resolution is anticipated, typically under close moni -\ntoring with serial serum human chorionic gonadotropin \n( ß -human chorionic gonadotropin) measurements ( 9 , 10 ). \nMedical management, primarily with methotrexate, is often \nsuitable for hemodynamically stable patients with unrup -\ntured ectopic pregnancies and low ß -human chorionic \ngonadotropin levels ( 11 ). These approaches allow for the \npreservation of fertility and avoid the risks associated with \nsurgery. They require strict follow-up to ensure complete res -\nolution and identify potential complications ( 12 , 13 ). Surgi -\ncal management, primarily salpingectomy, remains the \ncornerstone for patients with ruptured ectopic pregnancies \nor those who fail medical treatment. Advances in minimally \ninvasive surgical techniques have improved recovery times \nand reduced morbidity, highlighting the importance of early \ndiagnosis in facilitating optimal outcomes ( 14–16 ).\nDespite advances in the diagnosis of ectopic pregnancy, \nmany questions regarding the prevention, management, and \nfuture implications of this condition remain unanswered, \nespecially for the less commonly encountered types of \nectopic pregnancy ( 17 , 18 ). Historically, it has been re -\nsearchers who determined the unanswered research question \nput forward to funding bodies without necessarily using \nhealthcare professional, patient, and public involvement \n( 19 ).\nThe founder of the Cochrane Collaboration, Sir Iain \nChalmers, an obstetrician and gynecologist, has advocated \nfor research priorities to be identified through priority setting \npartnerships (PSPs) ( 20 ). These partnerships bring together \nhealthcare professionals, patients, and others. He established \nthe James Lind Alliance, which has published a handbook, \nwhich outlines the formal consensus methods each PSP \nshould use. The handbook emphasizes the importance of an \nopen and transparent process to identify and prioritize unan -\nswered research questions, known as research uncertainties, \nin a particular area of healthcare ( 21 ). The objective is to steer \nthe research agenda of funding organizations and re -\nsearchers toward prioritized research uncertainties as identi -\nfied following formal consensus methods ( 22 ). It is \nanticipated that such an approach will close the gap between \nwhat research is needed and what research is pursued ( 23 , \n24 ).\nResearch funders including the EU4Health program, Na -\ntional Institutes of Health, and National Institute for Health \nand Care Research, have endorsed such an approach ( 25 ) \nhighlighting PSPs as the most appropriate mechanism to \nidentify unanswered research questions and favor this \napproach within the application process ( 26 ).\nThis international collaboration has brought healthcare \nprofessionals, researchers, and people with lived experience \nof ectopic pregnancy together to establish the PSP for \nEctopic Pregnancy tasked with determining the future \nresearch priorities for ectopic pregnancy.\nMATERIALS AND METHODS\nTo oversee the PSP, a steering group consisting of 23 stake -\nholders—13 women and 10 men—from 10 countries on 6 con -\ntinents was established. This supervisory group comprised of \n20 healthcare professionals with expertise in ectopic preg -\nnancy, 9 of whom are academic clinicians, and 3 people \nwith lived experience of ectopic pregnancy, including the di -\nrector of the Ectopic Pregnancy Trust. The steering group was \nconvened during the development of the study protocol, \nbefore the launch of the initial survey and interim prioritiza -\ntion surveys, and before the consensus development meet -\nings. A systematic review of registered, progressing, and \ncompleted priority setting research settings assisted with \nthe planning and delivery of the study ( 27 ). The steering \ngroup included members with extensive experience in \ndesigning and leading research studies for ectopic pregnancy \nand with experience in using formal consensus science \nmethods ( 27–30 ). The scope of the study, as determined by \n2 VOL. ■ NO. ■ / ■ 2025 \n\n\nthe study steering committee, encompasses all types of \nectopic pregnancy. It was also decided that the scope \nwould include causes, prevention, diagnosis, treatment, \nand the medium- and longer-term impacts for all types of \nectopic pregnancy.\nResearch priorities were developed in a 3-stage process \nusing formal consensus methods advocated by the James \nLind Alliance ( 22 ).\nStage 1: identifying research uncertainties\nThe first stage was to gather potential research uncertainties. \nResearch recommendations were extracted from clinical \npractice guidelines and Cochrane systematic reviews, perti -\nnent to ectopic pregnancy, which were identified by search -\ning bibliographical databases, including CENTRAL, Embase, \nInternational Guideline Library, and MEDLINE, by two mem -\nbers of the steering group independent of one another ( 18 ). \nResearch recommendations were extracted verbatim from \nclinical practice guidelines and Cochrane reviews. These \nwere reviewed by three members of the steering group and \nformatted into appropriate research questions (T.A., J.M.N. \nD., M.M.). Differences in opinion were resolved by discussion \nwith the steering group. Stakeholders were recruited through \npatient advocacy groups and charities (e.g., the Ectopic Preg -\nnancy Trust and Miscarriage Association); professional \nwomen’s health channels such as the Association of Early \nPregnancy Units; hospital research networks; and, finally, \nthe European Society of Human Reproduction and \nEmbryology.\nPotential research uncertainties were gathered through \nan online survey of healthcare professionals, people with \nlived experience of ectopic pregnancy, and other stake -\nholders. The format of the survey was adapted from a previ -\nous survey developed by the PSP for infertility ( 28 ).They \nwere recruited through professional networks and patient \nadvocacy mailing lists. Recruitment was supported by an \nactive social media campaign. Potential participants received \nan explanatory video abstract, a plain language summary, \nand survey instructions. Before completing the survey, par -\nticipants provided demographic details, including age, sex, \nand geographical location, and information pertaining to \ntheir professional or personal experience of ectopic preg -\nnancy. Participants were invited to suggest up to 9 research \nquestions related to ectopic pregnancy that they considered \nunanswered via open-ended questions. Participants were \nencouraged to propose up to 3 research questions important \nto them on tubal ectopic pregnancy, cesarean section scar \nectopic pregnancy, and rarer types of ectopic pregnancy, \nincluding abdominal, cervical, and ovarian ectopic preg -\nnancy. Prompts in the form of example questions were pro -\nvided to participants to avoid confusion. To increase \naccessibility, there was an option to adapt the font size, \nfont color, and web page format as well as an embedded \ntranslation option within the Qualtrics software, which \nenabled participants to translate the survey into 78 other lan -\nguages. The survey was designed to be compatible and user- \nfriendly on desktops, mobile phones, and other screens to \noptimize participation and meaningful engagement. The \ninitial survey was open for 6 months.\nFour members of the steering committee (T.A., J.M.N.D., \nM.O., M.M.) separately collated the data from the systematic \nreview and online survey. All duplicate questions, ambig -\nuous questions, and questions outside the scope of the study \nwere removed from the long list of potential research uncer -\ntainties after discussing within this subset of the steering \ngroup, followed by review from the wider steering commit -\ntee, if agreement could not be reached. Questions that had \nalready been answered by previous research were also \nremoved. Evidence was gathered with targeted literature \nsearches within 5 databases (Medline, Cochrane, Embase, CI -\nNAHL, and Scopus) in addition to evaluation of international \nand national societal guidelines. The data extracted were \nthen evaluated using the Grading of Recommendations \nAssessment, Development and Evaluation system ( www. \ngradeworkinggroup.org ) with meta-analyses and systematic \nreviews considered the highest-quality evidence. Questions \nwere deemed to be ‘ ‘unanswered’ ’ if there was not any recent, \nhigh-quality research that generated conclusive results \navailable.\nAfter this, each member of the steering group was indi -\nvidually consulted to assess whether the research question \nhad been answered. During this stage, the steering group \nrefined the wording of potential research uncertainties ex -\ntracted from the initial survey to improve clarity without de -\ntracting from the crux of the research question. Categories \nwere not identified before this stage. An iterative process, \nwhereby a thematic review of submitted research uncer -\ntainties was undertaken, consequently identified 4 over -\narching categories: tubal ectopic pregnancy; cesarean \nsection scar ectopic pregnancy; rarer types of ectopic preg -\nnancy; and, finally, impact of diagnosis, policy, and organi -\nzation of care for ectopic pregnancy. Final allocation of the \nindividual research uncertainties to these specific categories \nwas evaluated by the steering group.\nStage 2: interim prioritization\nThe long list of rationalized research uncertainties was \nentered into an interim prioritization survey. Initial survey \nparticipants were invited to participate in the survey by using \nthe same dissemination channels. Before completing the sur -\nvey, participants provided demographic details, including \nage, sex, and geographical location, and information per -\ntaining to their professional or personal experience of \nectopic pregnancy. Participants were invited to select 5 \nresearch uncertainties from each thematic category they \nconsidered most important. After the survey had closed, \nquestions were ranked on the basis of the frequency in which \nthey had been chosen by participants. The long list of \nresearch uncertainties to be entered into the modified nomi -\nnal group technique (NGT) was generated by including 15 \nquestions, which were most frequently selected by interim \nprioritization survey participants. The interim prioritization \nsurvey was open for 4 months.\nVOL. ■ NO. ■ / ■ 2025 3 \nFertil Steril®\n\n\nStage 3: final prioritization\nThe modified NGT is a structured method used for group \ndecision-making that encourages input from all participants \nand ensures equal participation. An adaptation of the orig -\ninal NGT was designed to foster a more collaborative process. \nAlthough the modified nominal group method does not rely \non statistical power, it was agreed during a steering commit -\ntee meeting that between 15 and 35 people across the various \nstakeholder backgrounds would be sufficient ( 21 ). This num -\nber has yielded sufficient results and assured validity in other \nsettings ( 31 ).\nAll previous participants of the surveys were invited to \nattend either 1 of the 2 virtual interim prioritization work -\nshops: the in-person workshop or the final hybrid prioritiza -\ntion meeting.\nEach workshop was chaired by a member of the study \ncommittee who would first discuss the purpose of the session \nas well as set expectations for participants by mapping out \nhow the process will unfold. Each meeting included a \nmixture of healthcare professionals, people with lived expe -\nrience of ectopic pregnancy, and other key stakeholders.\nDuring the consensus building workshops, each partici -\npant was asked to choose the research uncertainty that \nthey considered the most important. After this, the facilitator \ncalled on each participant to present their priorities in a \nround-robin format. After each participant shared which \nresearch question was deemed the most important, the chair \nfacilitated a group discussion of each research uncertainty to \nclarify its context and meaning, offering an opportunity to \nfurther combine or refine research uncertainties as needed. \nThe research uncertainties were prioritized, and at the end \nof each meeting, these results were then taken forward to \nthe next meeting. During the final hybrid prioritization \nmeeting, the results of the virtual and in-person interim pri -\noritization meetings were presented. The rankings from the 3 \ngroups were aggregated into a single ranking order and pre -\nsented to the entire group. Participants were, again, invited \nto discuss the ordering of the research uncertainties. By the \nend of the discussion, the research uncertainties were placed \nin a final ranked order. The final language of each research \nuncertainty was formulated by the steering committee to \ncede flexibility to future researchers to design studies with \nstakeholder consultation; develop feasibility studies with \nthe objective of establishing interventions; and, finally, \nenable researchers to select appropriate outcome measures.\nEthics and funding\nEthics approval was obtained from Monash University (refer -\nence HREC/80401/MonH-2021-284721), and funding for the \nproject was provided by the Ectopic Pregnancy Trust.\nTABLE 1 \nCharacteristics of the participants in a survey to identify the priorities for future ectopic pregnancy research. \nStakeholder demographics\nSurvey 1 \nInitial survey \nn � 855\nSurvey 2 \nInterim prioritization survey \nn � 413\nConsensus meeting \nFinal prioritization \nn � 37\nStakeholder group, n\nPeople with lived \nexperience of ectopic \npregnancy\n553 289 11\nHealthcare professionals\nDoctor 42 13 20\nNurse 7 3 3\nSonographer 1 2 1\nOther 3 0 2\nPrefer not to say 249 106 0\nSex, n\nFemale 622 312 26\nMale 17 5 11\nPrefer not to say 216 96 0\nAge (y), n\n≤ 20 6 1 0\n21–30 183 91 7\n31–39 356 177 13\n40–49 72 38 13\n50–59 17 9 4\n≥ 60 6 2 0\nPrefer not to say 215 95 0\nGeographical location, n\nAfrica 15 1 0\nAsia 25 2 1\nAustralia and New \nZealand\n26 7 2\nEurope 495 277 32\nNorth America 73 29 2\nSouth America 4 2 0\nPrefer not to say 217 95 0\nAjith. Top 10 priorities for ectopic pregnancy research. Fertil Steril 2025. \n4 VOL. ■ NO. ■ / ■ 2025 \n\n\nRESULTS\nThe initial survey was completed by 855 respondents from 35 \ncountries ( Table 1 ). A total of 1,220 potential research uncer -\ntainties were submitted ( Fig. 1 ). After review, 18 responses \n(2.1%) were excluded.\nClinical practice guidelines and Cochrane systematic re -\nviews relevant to ectopic pregnancy were identified by \nsearching bibliographical databases. The keywords used \nwere ‘ ‘ectopic pregnancy,’ ’ ‘ ‘tubal pregnancy,’ ’ ‘ ‘interstitial \npregnancy,’ ’ ‘ ‘cornual pregnancy,’ ’ ‘ ‘cervical pregnancy,’ ’ \n‘ ‘caesarean scar pregnancy,’ ’ ‘ ‘ovarian pregnancy,’ ’ ‘ ‘abdom -\ninal pregnancy,’ ’ ‘ ‘heterotopic pregnancy,’ ’ ‘ ‘pregnancy of \nunknown location,’ ’ and ‘ ‘extrauterine pregnancy.’ ’ The sys -\ntematic reviews were restricted to articles from years 2002 to \nDecember 2022 as well as limited to articles written in the \nEnglish language. The search strategy identified 194 records. \nAfter excluding 2 duplicate records, 192 titles and abstracts \nwere screened. Forty-three potentially relevant abstracts \nwere evaluated. Three clinical practice guidelines and 43 \nCochrane reviews met the inclusion criteria. Twenty-four \npotential research questions were extracted from research \nrecommendations.\nA long list of 1,220 potential research uncertainties were \nreviewed, 1,130 duplicate research uncertainties were \nremoved, 18 research uncertainties were considered out of \nscope, and 47 research uncertainties that had been answered \nby research were also removed.\nA rationalized list of 49 confirmed research uncertainties \nwas developed, which included 7 research uncertainties \nrelated to tubal ectopic pregnancy, 15 research uncertainties \nrelated to cesarean section scar ectopic pregnancy, 13 \nresearch uncertainties related to rarer types of ectopic preg -\nnancy, and 14 research uncertainties related to impact of \ndiagnosis, policy, and organization of care ( Supplemental \nFIGURE 1\nSurvey 1\nGathering uncertainties\n855 participants\n35 countries\n3 clinical practice guidelines\n1220 potential research questions submitted\n15 potential research questions\n9 potential research questions\n43 Cochrane systematic reviews\n18 excluded responses\nSurvey 2\nInterim prioritisation\n413 participants\n20 countries \nTop 10 research uncertainties for ectopic pregnancy\nConsensus meetings\nNominal group technique\n37 participants\n10 countries \n1130 duplicates\n47 answered by research\n34 not prioritised\n15 research uncertainties prioritised\n5 not prioritised\nGathering uncertainties\nPrioritising uncertainties\n49 confirmed research uncertainties \n Tubal ectopic pregnancy: n=7\n Caesarean section scar ectopic pregnancy: n=15\n Rare type ectopic pregnancy: n=13\n Impact of diagnosis, policy, and organisation of care: n=14\nOverview of research uncertainties. \nAjith. Top 10 priorities for ectopic pregnancy research. Fertil Steril 2025. \nVOL. ■ NO. ■ / ■ 2025 5 \nFertil Steril®\n\n\nTable 1 , available online). These confirmed research uncer -\ntainties were entered into an interim prioritization survey, \nwhich was completed by 413 respondents from 20 countries.\nTwenty-six healthcare professionals and 11 people with \npersonal experience of ectopic pregnancy from 10 countries \nparticipated in 1 of 4 consensus building meetings (1 in- \nperson meeting, 2 online meetings, and 1 hybrid meeting). \nThe modified NGT was used to prioritize the top 10 research \nuncertainties for ectopic pregnancy. Fifteen highly priori -\ntized research uncertainties were discussed during consensus \ndevelopment meetings ( Supplemental Table 2 ). The 15 highly \nprioritized research uncertainties were initially discussed by \n3 separate groups and at the end of the discussion they \nranked the research uncertainties. The rankings from the \nmeetings were aggregated into a single ranking order and \ndiscussed in a final consensus development meeting. Partic -\nipants were encouraged to discuss and finalize the rank order \nof the research priorities. The top 10 research priorities are \npresented in Figure 2 . In total, 15 research recommendations \nobtained from the systematic review in the initial evidence- \ngathering stage were incorporated within this top 10 research \npriority list.\nDISCUSSION\nThe PSP for Ectopic Pregnancy has brought together health -\ncare professionals, people with lived experience of ectopic \npregnancy, researchers, and other vital stakeholders to iden -\ntify the top 10 research priorities for future research. These \nresearch priorities are diverse and seek answers to questions \nregarding the organization of care, the evaluation of novel \ntreatments for rarer types of ectopic pregnancy, and \nexploring the medium- and longer-term impacts of ectopic \npregnancy. They highlight the importance of pursuing \nresearch that has often been overlooked, including address -\ning the emotional and psychological impact of ectopic preg -\nnancy, improving access to ectopic pregnancy treatment, \nand evaluating the economic impacts of ectopic pregnancy \nand associated treatment. Addressing these priorities will \nrequire different research methodologies, including popula -\ntion science, mixed methods, and laboratory-based science.\nStrengths and limitations\nThe James Lind Alliance has published a handbook contain -\ning guidance to inform the design, delivery, and \nFIGURE 2\n1) What is the minimum standard of care that people with ectopic \npregnancy should expect?\n2) Following treatment of ectopic pregnancy, what are the future fertility, \npregnancy, and childbirth outcomes?\n3) Can healthcare professional education be improved to increase quality of \ncare, including effectiveness, safety, and experience?\n4) Can a prediction tool be devised to determine the risk of developing an \nectopic pregnancy and the treatment outcome?\n5) Should tests to assess whether the fallopian tubes are blocked, and are \nfunctioning, be routinely offered following treatment of tubal and \ninterstitial ectopic pregnancy?\n6) What is the emotional and psychological impact of ectopic pregnancy, \nand how can we address this?\n7) What is the effectiveness and safety of different treatment options for \nless common types of ectopic pregnancy?\n8) Should routine early pregnancy ultrasound scan screening be offered for \npeople who have had a previous Caesarean section?\n9) What is the effectiveness and safety of routine early pregnancy \nultrasound scans as a screening tool for those at a greater risk of \ndeveloping a less common type of ectopic pregnancy?\n10) What is the economic cost of ectopic pregnancy?\nTop 10 research priorities in ectopic pregnancy research. \nAjith. Top 10 priorities for ectopic pregnancy research. Fertil Steril 2025. \n6 VOL. ■ NO. ■ / ■ 2025 \n\n\ndissemination of research priority setting studies ( 27 ). Our \nPSP followed this guidance to ensure the research priorities \nwere developed using an open and transparent process. We \nprioritized using formal consensus development methods \nto ensure that the top 10 research priorities were developed \nusing the most appropriate scientific methods. The study \ndesign, development, and delivery were also informed by a \nsystematic review of research priority setting studies relevant \nto women’s health and by engaging with colleagues with sig -\nnificant experience in using consensus development \nmethods ( 32 , 33 ).\nWith 855 respondents from 35 countries participating in \nthe initial survey, 413 respondents from 20 countries partici -\npating in the interim prioritization survey, and 37 partici -\npants from 10 countries included in the consensus \ndevelopment meetings, the global participation achieved in \nthis study should secure the generalizability of the results \nwithin an international context. The study included over \n800 people with lived experience of ectopic pregnancy, and \nthey suggested potential research uncertainties during the \ninitial survey. Their contribution was substantial throughout \nthe study including sharing their views regarding the impor -\ntance of research uncertainties during the interim prioritiza -\ntion survey and participating fully in the consensus \ndevelopment meeting that prioritized the final research pri -\norities. This consensus study is not without limitations. \nConsideration should be given to the representativeness of \nthe study participants. A disproportionate number of re -\nsponses were received from participants who identified as \nliving in Europe (495 participants, 57.9%) during the initial \nsurvey collecting possible research uncertainties. The steer -\ning group devised a strategy to reach out to diverse stake -\nholders across different countries; however, the snowball \nsampling method may have influenced the demographic \ndata accordingly. Furthermore, many participants in the \nstudy were female, which is to be expected because women \nare most directly affected by ectopic pregnancy, and a signif -\nicant proportion of women’s health clinicians are also fe -\nmale. The initial survey (n = 553, 64.7%) and interim \nprioritization survey (n = 289, 70.0%) received many re -\nsponses from people with lived experience of ectopic preg -\nnancy. This demonstrates success in engaging with a \nstakeholder group who has not traditionally contributed to \nectopic pregnancy research. However, it could potentially \nskew how the research uncertainties were identified and \nprioritized. To counteract this potential impact, the steering \ngroup convened regularly to ensure the scope and objectives \nof the study were adhered to in order to produce feasible and \nresearchable results.\nA notable portion of respondents did not provide their \ncharacteristics, which may skew the representation of \nvarious stakeholder groups. This also highlights the limited \nengagement associated with web-based surveys. To partici -\npate in the initial survey and interim prioritization survey, \na computer or smart device and internet access were \nrequired, and thus, the findings may include more partici -\npants from higher resource settings. Although the nondisclo -\nsure rate of demographic information is comparable to other \nsimilar studies, this could have affected the representative -\nness of the sample, potentially impacting the research uncer -\ntainties suggested. Ectopic pregnancy and pregnancy loss are \na deeply personal issue, and some participants may not have \nwanted identifiable data (e.g., name, country of origin, and \nethnicity) in the public domain. Appreciating the sensitivity \nof this topic, participants were instructed that, although \nproviding demographic information was useful, it was \nentirely optional.\nThe study followed the consensus methods advocated by \nthe James Lind Alliance and has been previously used by ten \nnational and 2 international PSPs within women’s health \n( 27 ). The thematic qualitative analysis and categorization \nof the initial survey data streamlined the process of formu -\nlating indicative research questions for the prioritization \nstage of the study. Although this ensured the breadth of \nthis subject was thoroughly investigated, it could lead to \nthe nuance of individual priorities being obscured. Meticu -\nlous assessment of indicative research questions was neces -\nsary to avoid developing broad research questions, which \ncould be difficult to investigate, and highly specific ques -\ntions, which may impede prioritization by spreading a key \ntheme over multiple research questions. Despite this rigorous \nprocess, there remains uncertainty regarding the optimal \nconsensus development method to prioritize research uncer -\ntainties ( 27 ). Further methodological research is required \nregarding the use of different consensus methods to identify \nresearch priorities. Additional contextual information could \npotentially have assisted participants in prioritizing the \nresearch uncertainties. Future methodological research \nshould determine whether additional contextual information \nalongside individual research uncertainties should be \noffered. This should include the number of people the \nresearch priority impacts upon, the feasibility of answering \nthe research priority, and the resources required to address \nthe research uncertainty.\nReflections on the research priorities\nThe research priorities highlight a fundamental area of \nresearch related to the understanding of the minimum stan -\ndard of care that people with ectopic pregnancy should \nexpect. Establishing a clear, evidence-based standard for \ndiagnosis, treatment, and follow-up care is critical for \nensuring that people with ectopic pregnancy receive the \nbest possible care, regardless of their location or healthcare \nsetting ( 34–36 ). This includes determining the most \neffective treatment methods, including expectant, medical, \nand/or surgical management, and how to ensure that \npatients are managed in a way that improves outcomes and \nminimizes risks ( 37–40 ). Research should also evaluate \nundergraduate and postgraduate educational interventions, \nwhich could improve healthcare professional education \n( 41–47 ). Healthcare professionals should be well equipped \nwith the latest knowledge and skills to diagnose ectopic \npregnancies early and accurately ( 48–52 ) and to manage \ntreatment effectively ( 4 ). This could involve updating \ntraining programs, refining clinical guidelines, and \nfostering a deeper understanding of the condition across \nVOL. ■ NO. ■ / ■ 2025 7 \nFertil Steril®\n\n\nprimary and secondary care to improve patient satisfaction \n( 53 ).\nAnother area the research priorities highlight is the \nimpact of ectopic pregnancy on medium- and longer-term \noutcomes, including future fertility and pregnancy outcomes \n( 54–60 ). It is important to understand how treatment for \nectopic pregnancy affects long-term reproductive health, \nincluding the risks of recurrence and the likelihood of suc -\ncessful future pregnancies ( 61–66 ). Research could provide \ninvaluable information for patients, enabling them to make \ninformed decisions about family planning after an ectopic \npregnancy. The role of the fallopian tubes in future fertility \nwarrants further exploration because tubal damage is a \ncommon cause and consequence of ectopic pregnancy ( 62 ). \nEvaluating whether routine testing to assess tubal patency \nand function should be enshrined in posttreatment care \nplan could help identify those at risk of subfertility or \nfuture complications. Contrary to this, the possible harm of \nconducting tubal patency and tubal function testing in all \npatients who have been diagnosed with a tubal ectopic \npregnancy has not been rigorously investigated. This \nexample demonstrates the importance of further research \ninto this area.\nThe research uncertainties identified have been designed \nto provide a broad foundation for researchers, clinicians, pa -\ntients, and funding bodies to consider and pursue without \nbeing too restrictive on the research agenda. A potential \nnegative impact of this is that the feasibility of undertaking \nsuch research was not considered during the process. \nConversely, we believe that these research objectives have \nnot been previously addressed due to limited consultation \nwith patients and limited funding in ectopic pregnancy \nresearch. Developing an international list of research prior -\nities through international consensus could lay the ground -\nwork for more international collaboration in addressing \nthese unanswered questions in ectopic pregnancy care.\nThe research priorities highlight the emotional and psy -\nchological impact of an ectopic pregnancy ( 67–70 ). The \nexperience of an ectopic pregnancy can be deeply \ntraumatic, often leading to feelings of grief, loss, and \nanxiety ( 57 , 71 ). Research focusing upon the psychological \neffects of ectopic pregnancy and the development of \nsupportive care strategies would help address this aspect of \nrecovery ( 72 , 73 ). Offering mental health support and \ncounseling as part of a comprehensive care plan could help \nalleviate the emotional burden of people with lived \nexperience of ectopic pregnancy and improve overall \npatient well-being ( 74–77 ).\nIn terms of clinical outcomes, the research priorities \ndemonstrate the need to evaluate the effectiveness and safety \nof different treatment options for less common types of \nectopic pregnancies, such as abdominal, cervical, and inter -\nstitial ( 58 , 78–85 ). These rare cases present unique \nchallenges, and there is currently limited evidence to guide \nmanagement decisions ( 86 ). Understanding the best \napproach for managing these types of ectopic pregnancies \nwill ensure that healthcare providers are equipped with the \nknowledge to provide optimal care in all ectopic pregnancy \ncases ( 13 , 15 , 17 , 87–94 ).\nEarly detection is crucial for improving outcomes, \nparticularly in individuals at higher risk ( 95–99 ). Research \ninto the role of routine early pregnancy ultrasound scans \nfor individuals who have had previous cesarean sections, \nor those with other risk factors, could enhance early \ndiagnosis and reduce the risk of undiagnosed ectopic \npregnancies ( 100–102 ). Ultrasound screening for those at \nhigher risk of developing rarer types of ectopic pregnancy \nis another area of the research priorities highlighted \nbecause it could help identify problematic pregnancies \nearlier and allow for timely intervention ( 103 ).\nUnderstanding the economic cost of ectopic pregnancy is \na vital component of future research ( 104–107 ). The direct \nand indirect costs of ectopic pregnancies, ranging \nfrom hospital admissions and treatments to long-term \nhealthcare needs and lost productivity, have significant im -\nplications for local, regional, and national healthcare sys -\ntems ( 108–111 ). Research into the economic burden of \nectopic pregnancy could guide resource allocation and help \npolicymakers make informed decisions about funding and \nsupport for ectopic pregnancy care ( 112 , 113 ).\nAddressing these research priorities will not only improve \nclinical outcomes and reduce the risks associated with ectopic \npregnancy but also enhance the emotional and psychological \ncare of patients. By deepening our understanding of ectopic \npregnancy and developing evidence-based approaches to \ntreatment, healthcare providers can better support individ -\nuals through what is often a challenging and potentially \nlife-changing experience.\nWider context\nThe study has developed a prioritized list of research uncer -\ntainties. The consensus methods have ensured that they \nrepresent the most pressing clinical needs as perceived by \nhealthcare professionals, people with lived experience of \nectopic pregnancy, and others. Funding organizations and \nresearchers should consider these top 10 priorities for ectopic \npregnancy research when setting their future research \nagenda. The selected list of research uncertainties should \nserve as a focus when making decisions regarding the alloca -\ntion of limited research resources.\nMany of the research priorities will require national and \ninternational collaboration. This is particularly true for \nresearch priorities that are related to the rarer types of ectopic \npregnancy, for example, cesarean scar ectopic pregnancies. \nSeveral countries, including the United Kingdom, have \ndeveloped national networks to undertake ectopic pregnancy \nresearch ( 112 ). For example, the GEM3 collaborative, based \nin the United Kingdom, has recently complete a multicenter \nrandomized trial evaluating the combination of gefitinib and \nmethotrexate to treat tubal ectopic pregnancy ( 114 ). Further \ndevelopment of national infrastructure in individual \ncounties is required ( 115 ). Collaboration should spread \nbeyond national boundaries and develop within an interna -\ntional setting. It is hoped that the development of a priori -\ntized research agenda could be an important enabler to \ndeepen international collaboration.\n8 VOL. ■ NO. ■ / ■ 2025 \n\n\nDevelopment of generic infrastructure could help foster \ncollaboration, including the use of minimum data sets, \nknown as core outcome sets, low-cost data repositories, \nand standardized approaches to the reporting of research \n( 115 ). A core outcome set has recently been developed for \nfuture ectopic pregnancy trials ( 116 ). Over 150 healthcare \nprofessionals, researchers, and patients have used formal \nconsensus development methods to identify a core outcome \nset for ectopic pregnancy research. Consensus definitions \nhave also been agreed for individual core outcomes, \nincluding a consensus definition for treatment success, reso -\nlution time of ectopic pregnancy, and adverse events. It is \nhoped that the core outcome set will provide a generic \nresearch tool to collect outcomes during research and stan -\ndardize the approach to research reporting.\nResearch priorities identified in this study correspond \nwith research priorities identified by the PSP for Infertility, \nincluding determining the emotional and psychological \nimpact of infertility, investigating the modifiable risk factors \nthat cause infertility, and identifying the optimal model of \ncare ( 28 ). Other similarities exist when considering the \nresearch uncertainties prioritized by the PSP for Endometri -\nosis ( 117 ), PSP for Miscarriage ( 118 ), and International Poly -\ncystic Ovary Syndrome Network ( 119 ).\nAnswering the prioritized research questions would \nrepresent a significant step forward for people with ectopic \npregnancy. A blended research strategy should offer the \noptimal pathway to improving clinical care and patient out -\ncomes. We recognize the important role of research that \nstems from fundamental science that does not have an imme -\ndiate clinical application, intellectual curiosity of individual \nresearchers, and research that is funded by patient organiza -\ntions or special interest groups. Perhaps the most important \npart of this process of establishing the top 10 research prior -\nities for ectopic pregnancy has been strengthening the rela -\ntionships between partner organizations, healthcare \nprofessionals, and people with lived experience of ectopic \npregnancy.\nCONCLUSION\nDespite the increasing prevalence of ectopic pregnancy, sig -\nnificant research gaps remain. The PSP has highlighted the \ntop 10 research priorities for ectopic pregnancy, as collec -\ntively determined by key stakeholders. Using the rigorous \nJames Lind Alliance methodology and with the active \ninvolvement of both patients and healthcare professionals, \nthese research questions were crafted to directly enhance pa -\ntient care. Ultimately, we aim for the top 10 research ques -\ntions identified in this study to serve as a compelling \nrationale for research funding bodies to allocate resources \ntoward the areas of most critical clinical need.\nCRediT Authorship Contribution Statement\nTara Ajith: Writing – review & editing, Writing – original \ndraft, Visualization, Validation, Software, Resources, Project \nadministration, Methodology, Investigation, Formal anal -\nysis, Data curation, Conceptualization. Kurt T. Barnhart: \nWriting – review & editing, Supervision, Data curation. \nRuth Bender Atik: Writing – review & editing, Supervision, \nData curation. Tom Bourne: Writing – review & editing, Su -\npervision, Data curation. Krystle Chong: Writing – review & \nediting, Supervision, Data curation. George Condous: \nWriting – review & editing, Supervision, Data curation. Pa -\nmela I. Causa Andrieu: Writing – review & editing, Supervi -\nsion, Data curation. Grigorios Derdelis: Writing – review & \nediting, Supervision, Data curation. Andrew W. Horne: \nWriting – review & editing, Supervision, Data curation. \nJudith A.F. Huirne: Writing – review & editing, Supervision, \nData curation. Davor Jurkovic: Writing – review & editing, \nSupervision, Data curation. Emma Kirk: Writing – review \n& editing, Supervision, Data curation. Ernest H.Y. Ng: \nWriting – review & editing, Supervision, Data curation. Ri -\ncardo F. Savaris: Writing – review & editing, Supervision, \nData curation. Janneke van’t Hooft: Writing – review & ed -\niting, Supervision, Data curation. Madelon van Wily: \nWriting – review & editing, Supervision, Data curation. Liesl \nde Waard: Writing – review & editing, Supervision, Data cu -\nration. Maria P. Velez: Writing – review & editing, Supervi -\nsion, Data curation. Jian Zhang: Writing – review & editing, \nSupervision, Data curation. James M.N. Duffy: Writing – re -\nview & editing, Writing – original draft, Visualization, Vali -\ndation, Supervision, Software, Resources, Project \nadministration, Methodology, Investigation, Funding acqui -\nsition, Formal analysis, Data curation, Conceptualization. \nMaria Memtsa: Writing – review & editing, Writing – orig -\ninal draft, Visualization, Validation, Supervision, Software, \nResources, Project administration, Methodology, Investiga -\ntion, Funding acquisition, Formal analysis, Data curation, \nConceptualization. Munira Oza: Writing – review & editing, \nVisualization, Validation, Supervision, Software, Resources, \nProject administration, Methodology, Investigation, Funding \nacquisition, Formal analysis, Data curation, Conceptualiza -\ntion. Ben W. Mol: Writing – review & editing, Supervision, \nProject administration, Data curation, Conceptualization.\nDeclaration of Interests\nT.A. has nothing to disclose. K.T.B. has nothing to disclose. R. \nB.A. reports that the Miscarriage Association National Direc -\ntor of this patient support organization, with no fiduciary in -\nterest. T.B. has nothing to disclose. K.C. has nothing to \ndisclose. G.C. reports MRFF funding outside the submitted \nwork and consulting fees from GE HealthCare and Samsung. \nP.I.C.A. has nothing to disclose. G.D. has nothing to disclose. \nA.W.H. reports grant funding from EU, UKRI, NIHR, CSO, \nWellbeing of Women, and Roche Diagnostics outside the \nsubmitted work; lecture fees from Gedeon Richter and Ther -\namex; UK Patent 2217921.1; TSC Chair for PANDA clinical \ntrial; President-elect of the World Endometriosis Society; \nCo-Editor-in-Chief of Reproduction and Fertility ; Trustee \nand Medical Advisor to Endometriosis UK; and Specialty \nAdvisor to the Scottish Government’s Chief Medical Officer \nfor Obstetrics and Gynaecology. J.A.F.H. has nothing to \ndisclose. D.J. has nothing to disclose. E.K. reports travel sup -\nport from Medtronics meeting on pelvic venous disorders. E. \nH.Y.N. has nothing to disclose. R.F.S. has nothing to disclose. \nJ.v.H. has nothing to disclose. M.v.W. has nothing to \ndisclose. L.d.W. has nothing to disclose. M.P.V. has nothing \nVOL. ■ NO. ■ / ■ 2025 9 \nFertil Steril®\n\n\nto disclose. J.Z. has nothing to disclose. J.M.N.D. has nothing \nto disclose. M.M. has nothing to disclose. M.O. has nothing to \ndisclose. B.W.M. reports research funding from Merck KGaA \noutside the submitted work; consulting fees from Merck \nKGaA, Organon, and Norgine; and travel support from Merck \nKGaA. \nSUPPLEMENTAL MATERIAL\nSupplemental data for this article can be found online at \nhttps://doi.org/10.1016/j.fertnstert.2025.09.032 .\nREFERENCES\n1 . ESHRE working group on Ectopic Pregnancy, Kirk E, Ankum P, Jakab A, Le \nClef N, Ludwin A, et al. Terminology for describing normally sited and \nectopic pregnancies on ultrasound: ESHRE recommendations for good \npractice. Hum Reprod Open 2020;2020:hoaa055 . \n2 . Chong KY, de Waard L, Oza M, van Wely M, Jurkovic D, Memtsa M, et al. \nEctopic pregnancy. Nat Rev Dis Primers 2024;10:94 . \n3 . Sokalska A, Rambhatla A, Dudley C, Bhagavath B. Nontubal ectopic \npregnancies: overview of diagnosis and treatment. Fertil Steril 2023; \n120:553–62 . \n4 . 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