Top 10 priorities for future ectopic pregnancy research: an international consensus development study

To determine the future priorities for ectopic pregnancy research. Design: Potential research questions were collated from an initial international survey, a systematic review of clinical practice guide - lines, and Cochrane systematic reviews. A rationalized list of confirmed research uncertainties was prioritized in an interim interna - tional survey. Prioritized research uncertainties were discussed during a consensus development meeting. Using a formal consensus development method, the modified nominal group technique, diverse stakeholders identified the top 10 research priorities for future ectopic pregnancy research. Subjects: Healthcare professionals, people with lived experience of ectopic pregnancy, and others were brought together in an open and transparent process using formal consensus methods advocated by the James Lind Alliance. Exposure: Not applicable. Main Outcome Measures: Top 10 research priorities for ectopic pregnancy. Received June 17, 2025; revised September 22, 2025; accepted September 23, 2025. Supported by the Ectopic Pregnancy Trust, 483 Green Lanes, London, N13 4BS, United Kingdom Data 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 - nal pre and/or post publication for review or query upon request. The appropriate checklist for this study design was followed. Correspondence: Tara Ajith, MBBS (Hons), Royal Free London NHS Foundation Trust, Pond Street, Rosslyn Hill, London, NW3 2QG, United Kingdom (E-mail: [email protected] ). Fertil Steril® Vol. ■ , No. ■ , ■ 2025 0015-0282 Copyright ©2025 The Authors. Published by Elsevier Inc. on behalf of the American Society for Reproductive Medicine. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). https://doi.org/10.1016/j.fertnstert.2025.09.032 VOL. ■ NO. ■ / ■ 2025 1

The initial survey was completed by 855 participants from 35 countries, and 1,220 potential research questions were sub - mitted. Three clinical practice guidelines and 43 Cochrane systematic reviews identified a further 24 potential research questions. A rationalized list of 49 confirmed research uncertainties was entered into an interim prioritization survey completed by 413 respon - dents from 20 countries. The top 10 research priorities were identified during a consensus development meeting involving 37 partic - ipants from 10 countries. These research priorities are diverse and seek answers to questions regarding prevention, treatment, and the longer-term impact of ectopic pregnancy.

We anticipate that the identified research priorities, developed to specifically highlight the most pressing clinical needs as perceived by healthcare professionals, people with lived experience of ectopic pregnancy, and others, will help research funding organizations and researchers to develop their future research agenda. (Fertil Steril ® 2025; ■ : ■ – ■ . © 2025 by American Society for Reproductive Medicine.) Key Words: Ectopic pregnancy, research priorities, reproductive medicine, consensus science methods, modified Delphi method A n ectopic pregnancy is a potentially life-threatening condition where a pregnancy implants abnormally to a site other than within the uterine endometrial cavity ( 1 ). They most commonly occur within the fallopian tubes (95%) but may also be present in other sites such as the ovary (1.14%–3.12%), abdominal cavity (1%), or cervix (0.4%) ( 2 , 3 ). Ectopic pregnancies affect between 1% and 2% of all pregnancies ( 4 ). The global incidence of ectopic pregnancy varies widely, influenced by factors such as access to healthcare; prevalence of risk factors, including pelvic in - flammatory disease; assisted reproductive technologies; pre - vious gynecological surgery; and sociodemographic considerations ( 5–8 ). Management of ectopic pregnancy has evolved signifi - cantly, encompassing expectant, medical, and surgical ap - proaches. Expectant management, although less commonly employed, may be appropriate in selected cases where spon - taneous resolution is anticipated, typically under close moni - toring with serial serum human chorionic gonadotropin ( ß -human chorionic gonadotropin) measurements ( 9 , 10 ). Medical management, primarily with methotrexate, is often suitable for hemodynamically stable patients with unrup - tured ectopic pregnancies and low ß -human chorionic gonadotropin levels ( 11 ). These approaches allow for the preservation of fertility and avoid the risks associated with surgery. They require strict follow-up to ensure complete res - olution and identify potential complications ( 12 , 13 ). Surgi - cal management, primarily salpingectomy, remains the cornerstone for patients with ruptured ectopic pregnancies or those who fail medical treatment. Advances in minimally invasive surgical techniques have improved recovery times and reduced morbidity, highlighting the importance of early diagnosis in facilitating optimal outcomes ( 14–16 ). Despite advances in the diagnosis of ectopic pregnancy, many questions regarding the prevention, management, and future implications of this condition remain unanswered, especially for the less commonly encountered types of ectopic pregnancy ( 17 , 18 ). Historically, it has been re - searchers who determined the unanswered research question put forward to funding bodies without necessarily using healthcare professional, patient, and public involvement ( 19 ). The founder of the Cochrane Collaboration, Sir Iain Chalmers, an obstetrician and gynecologist, has advocated for research priorities to be identified through priority setting partnerships (PSPs) ( 20 ). These partnerships bring together healthcare professionals, patients, and others. He established the James Lind Alliance, which has published a handbook, which outlines the formal consensus methods each PSP should use. The handbook emphasizes the importance of an open and transparent process to identify and prioritize unan - swered research questions, known as research uncertainties, in a particular area of healthcare ( 21 ). The objective is to steer the research agenda of funding organizations and re - searchers toward prioritized research uncertainties as identi - fied following formal consensus methods ( 22 ). It is anticipated that such an approach will close the gap between what research is needed and what research is pursued ( 23 , 24 ). Research funders including the EU4Health program, Na - tional Institutes of Health, and National Institute for Health and Care Research, have endorsed such an approach ( 25 ) highlighting PSPs as the most appropriate mechanism to identify unanswered research questions and favor this approach within the application process ( 26 ). This international collaboration has brought healthcare professionals, researchers, and people with lived experience of ectopic pregnancy together to establish the PSP for Ectopic Pregnancy tasked with determining the future research priorities for ectopic pregnancy.

To oversee the PSP, a steering group consisting of 23 stake - holders—13 women and 10 men—from 10 countries on 6 con - tinents was established. This supervisory group comprised of 20 healthcare professionals with expertise in ectopic preg - nancy, 9 of whom are academic clinicians, and 3 people with lived experience of ectopic pregnancy, including the di - rector of the Ectopic Pregnancy Trust. The steering group was convened during the development of the study protocol, before the launch of the initial survey and interim prioritiza - tion surveys, and before the consensus development meet - ings. A systematic review of registered, progressing, and completed priority setting research settings assisted with the planning and delivery of the study ( 27 ). The steering group included members with extensive experience in designing and leading research studies for ectopic pregnancy and with experience in using formal consensus science

( 27–30 ). The scope of the study, as determined by 2 VOL. ■ NO. ■ / ■ 2025 the study steering committee, encompasses all types of ectopic pregnancy. It was also decided that the scope would include causes, prevention, diagnosis, treatment, and the medium- and longer-term impacts for all types of ectopic pregnancy. Research priorities were developed in a 3-stage process using formal consensus methods advocated by the James Lind Alliance ( 22 ). Stage 1: identifying research uncertainties The first stage was to gather potential research uncertainties. Research recommendations were extracted from clinical practice guidelines and Cochrane systematic reviews, perti - nent to ectopic pregnancy, which were identified by search - ing bibliographical databases, including CENTRAL, Embase, International Guideline Library, and MEDLINE, by two mem - bers of the steering group independent of one another ( 18 ). Research recommendations were extracted verbatim from clinical practice guidelines and Cochrane reviews. These were reviewed by three members of the steering group and formatted into appropriate research questions (T.A., J.M.N. D., M.M.). Differences in opinion were resolved by discussion with the steering group. Stakeholders were recruited through patient advocacy groups and charities (e.g., the Ectopic Preg - nancy Trust and Miscarriage Association); professional women’s health channels such as the Association of Early Pregnancy Units; hospital research networks; and, finally, the European Society of Human Reproduction and Embryology. Potential research uncertainties were gathered through an online survey of healthcare professionals, people with lived experience of ectopic pregnancy, and other stake - holders. The format of the survey was adapted from a previ - ous survey developed by the PSP for infertility ( 28 ).They were recruited through professional networks and patient advocacy mailing lists. Recruitment was supported by an active social media campaign. Potential participants received an explanatory video abstract, a plain language summary, and survey instructions. Before completing the survey, par - ticipants provided demographic details, including age, sex, and geographical location, and information pertaining to their professional or personal experience of ectopic preg - nancy. Participants were invited to suggest up to 9 research questions related to ectopic pregnancy that they considered unanswered via open-ended questions. Participants were encouraged to propose up to 3 research questions important to them on tubal ectopic pregnancy, cesarean section scar ectopic pregnancy, and rarer types of ectopic pregnancy, including abdominal, cervical, and ovarian ectopic preg - nancy. Prompts in the form of example questions were pro - vided to participants to avoid confusion. To increase accessibility, there was an option to adapt the font size, font color, and web page format as well as an embedded translation option within the Qualtrics software, which enabled participants to translate the survey into 78 other lan - guages. The survey was designed to be compatible and user- friendly on desktops, mobile phones, and other screens to optimize participation and meaningful engagement. The initial survey was open for 6 months. Four members of the steering committee (T.A., J.M.N.D., M.O., M.M.) separately collated the data from the systematic review and online survey. All duplicate questions, ambig - uous questions, and questions outside the scope of the study were removed from the long list of potential research uncer - tainties after discussing within this subset of the steering group, followed by review from the wider steering commit - tee, if agreement could not be reached. Questions that had already been answered by previous research were also removed. Evidence was gathered with targeted literature searches within 5 databases (Medline, Cochrane, Embase, CI - NAHL, and Scopus) in addition to evaluation of international and national societal guidelines. The data extracted were then evaluated using the Grading of Recommendations Assessment, Development and Evaluation system ( www. gradeworkinggroup.org ) with meta-analyses and systematic reviews considered the highest-quality evidence. Questions were deemed to be ‘ ‘unanswered’ ’ if there was not any recent, high-quality research that generated conclusive results available. After this, each member of the steering group was indi - vidually consulted to assess whether the research question had been answered. During this stage, the steering group refined the wording of potential research uncertainties ex - tracted from the initial survey to improve clarity without de - tracting from the crux of the research question. Categories were not identified before this stage. An iterative process, whereby a thematic review of submitted research uncer - tainties was undertaken, consequently identified 4 over - arching categories: tubal ectopic pregnancy; cesarean section scar ectopic pregnancy; rarer types of ectopic preg - nancy; and, finally, impact of diagnosis, policy, and organi - zation of care for ectopic pregnancy. Final allocation of the individual research uncertainties to these specific categories was evaluated by the steering group. Stage 2: interim prioritization The long list of rationalized research uncertainties was entered into an interim prioritization survey. Initial survey participants were invited to participate in the survey by using the same dissemination channels. Before completing the sur - vey, participants provided demographic details, including age, sex, and geographical location, and information per - taining to their professional or personal experience of ectopic pregnancy. Participants were invited to select 5 research uncertainties from each thematic category they considered most important. After the survey had closed, questions were ranked on the basis of the frequency in which they had been chosen by participants. The long list of research uncertainties to be entered into the modified nomi - nal group technique (NGT) was generated by including 15 questions, which were most frequently selected by interim prioritization survey participants. The interim prioritization survey was open for 4 months. VOL. ■ NO. ■ / ■ 2025 3 Fertil Steril® Stage 3: final prioritization The modified NGT is a structured method used for group decision-making that encourages input from all participants and ensures equal participation. An adaptation of the orig - inal NGT was designed to foster a more collaborative process. Although the modified nominal group method does not rely on statistical power, it was agreed during a steering commit - tee meeting that between 15 and 35 people across the various stakeholder backgrounds would be sufficient ( 21 ). This num - ber has yielded sufficient results and assured validity in other settings ( 31 ). All previous participants of the surveys were invited to attend either 1 of the 2 virtual interim prioritization work - shops: the in-person workshop or the final hybrid prioritiza - tion meeting. Each workshop was chaired by a member of the study committee who would first discuss the purpose of the session as well as set expectations for participants by mapping out how the process will unfold. Each meeting included a mixture of healthcare professionals, people with lived expe - rience of ectopic pregnancy, and other key stakeholders. During the consensus building workshops, each partici - pant was asked to choose the research uncertainty that they considered the most important. After this, the facilitator called on each participant to present their priorities in a round-robin format. After each participant shared which research question was deemed the most important, the chair facilitated a group discussion of each research uncertainty to clarify its context and meaning, offering an opportunity to further combine or refine research uncertainties as needed. The research uncertainties were prioritized, and at the end of each meeting, these results were then taken forward to the next meeting. During the final hybrid prioritization meeting, the results of the virtual and in-person interim pri - oritization meetings were presented. The rankings from the 3 groups were aggregated into a single ranking order and pre - sented to the entire group. Participants were, again, invited to discuss the ordering of the research uncertainties. By the end of the discussion, the research uncertainties were placed in a final ranked order. The final language of each research uncertainty was formulated by the steering committee to cede flexibility to future researchers to design studies with stakeholder consultation; develop feasibility studies with the objective of establishing interventions; and, finally, enable researchers to select appropriate outcome measures. Ethics and funding Ethics approval was obtained from Monash University (refer - ence HREC/80401/MonH-2021-284721), and funding for the project was provided by the Ectopic Pregnancy Trust. TABLE 1 Characteristics of the participants in a survey to identify the priorities for future ectopic pregnancy research. Stakeholder demographics Survey 1 Initial survey n � 855 Survey 2 Interim prioritization survey n � 413 Consensus meeting Final prioritization n � 37 Stakeholder group, n People with lived experience of ectopic pregnancy 553 289 11 Healthcare professionals Doctor 42 13 20 Nurse 7 3 3 Sonographer 1 2 1 Other 3 0 2 Prefer not to say 249 106 0 Sex, n Female 622 312 26 Male 17 5 11 Prefer not to say 216 96 0 Age (y), n ≤ 20 6 1 0 21–30 183 91 7 31–39 356 177 13 40–49 72 38 13 50–59 17 9 4 ≥ 60 6 2 0 Prefer not to say 215 95 0 Geographical location, n Africa 15 1 0 Asia 25 2 1 Australia and New Zealand 26 7 2 Europe 495 277 32 North America 73 29 2 South America 4 2 0 Prefer not to say 217 95 0 Ajith. Top 10 priorities for ectopic pregnancy research. Fertil Steril 2025. 4 VOL. ■ NO. ■ / ■ 2025

The initial survey was completed by 855 respondents from 35 countries ( Table 1 ). A total of 1,220 potential research uncer - tainties were submitted ( Fig. 1 ). After review, 18 responses (2.1%) were excluded. Clinical practice guidelines and Cochrane systematic re - views relevant to ectopic pregnancy were identified by searching bibliographical databases. The keywords used were ‘ ‘ectopic pregnancy,’ ’ ‘ ‘tubal pregnancy,’ ’ ‘ ‘interstitial pregnancy,’ ’ ‘ ‘cornual pregnancy,’ ’ ‘ ‘cervical pregnancy,’ ’ ‘ ‘caesarean scar pregnancy,’ ’ ‘ ‘ovarian pregnancy,’ ’ ‘ ‘abdom - inal pregnancy,’ ’ ‘ ‘heterotopic pregnancy,’ ’ ‘ ‘pregnancy of unknown location,’ ’ and ‘ ‘extrauterine pregnancy.’ ’ The sys - tematic reviews were restricted to articles from years 2002 to December 2022 as well as limited to articles written in the English language. The search strategy identified 194 records. After excluding 2 duplicate records, 192 titles and abstracts were screened. Forty-three potentially relevant abstracts were evaluated. Three clinical practice guidelines and 43 Cochrane reviews met the inclusion criteria. Twenty-four potential research questions were extracted from research recommendations. A long list of 1,220 potential research uncertainties were reviewed, 1,130 duplicate research uncertainties were removed, 18 research uncertainties were considered out of scope, and 47 research uncertainties that had been answered by research were also removed. A rationalized list of 49 confirmed research uncertainties was developed, which included 7 research uncertainties related to tubal ectopic pregnancy, 15 research uncertainties related to cesarean section scar ectopic pregnancy, 13 research uncertainties related to rarer types of ectopic preg - nancy, and 14 research uncertainties related to impact of diagnosis, policy, and organization of care ( Supplemental FIGURE 1 Survey 1 Gathering uncertainties 855 participants 35 countries 3 clinical practice guidelines 1220 potential research questions submitted 15 potential research questions 9 potential research questions 43 Cochrane systematic reviews 18 excluded responses Survey 2 Interim prioritisation 413 participants 20 countries Top 10 research uncertainties for ectopic pregnancy Consensus meetings Nominal group technique 37 participants 10 countries 1130 duplicates 47 answered by research 34 not prioritised 15 research uncertainties prioritised 5 not prioritised Gathering uncertainties Prioritising uncertainties 49 confirmed research uncertainties  Tubal ectopic pregnancy: n=7  Caesarean section scar ectopic pregnancy: n=15  Rare type ectopic pregnancy: n=13  Impact of diagnosis, policy, and organisation of care: n=14 Overview of research uncertainties. Ajith. Top 10 priorities for ectopic pregnancy research. Fertil Steril 2025. VOL. ■ NO. ■ / ■ 2025 5 Fertil Steril® Table 1 , available online). These confirmed research uncer - tainties were entered into an interim prioritization survey, which was completed by 413 respondents from 20 countries. Twenty-six healthcare professionals and 11 people with personal experience of ectopic pregnancy from 10 countries participated in 1 of 4 consensus building meetings (1 in- person meeting, 2 online meetings, and 1 hybrid meeting). The modified NGT was used to prioritize the top 10 research uncertainties for ectopic pregnancy. Fifteen highly priori - tized research uncertainties were discussed during consensus development meetings ( Supplemental Table 2 ). The 15 highly prioritized research uncertainties were initially discussed by 3 separate groups and at the end of the discussion they ranked the research uncertainties. The rankings from the meetings were aggregated into a single ranking order and discussed in a final consensus development meeting. Partic - ipants were encouraged to discuss and finalize the rank order of the research priorities. The top 10 research priorities are presented in Figure 2 . In total, 15 research recommendations obtained from the systematic review in the initial evidence- gathering stage were incorporated within this top 10 research priority list.

The PSP for Ectopic Pregnancy has brought together health - care professionals, people with lived experience of ectopic pregnancy, researchers, and other vital stakeholders to iden - tify the top 10 research priorities for future research. These research priorities are diverse and seek answers to questions regarding the organization of care, the evaluation of novel treatments for rarer types of ectopic pregnancy, and exploring the medium- and longer-term impacts of ectopic pregnancy. They highlight the importance of pursuing research that has often been overlooked, including address - ing the emotional and psychological impact of ectopic preg - nancy, improving access to ectopic pregnancy treatment, and evaluating the economic impacts of ectopic pregnancy and associated treatment. Addressing these priorities will require different research methodologies, including popula - tion science, mixed methods, and laboratory-based science. Strengths and limitations The James Lind Alliance has published a handbook contain - ing guidance to inform the design, delivery, and FIGURE 2 1) What is the minimum standard of care that people with ectopic pregnancy should expect? 2) Following treatment of ectopic pregnancy, what are the future fertility, pregnancy, and childbirth outcomes? 3) Can healthcare professional education be improved to increase quality of care, including effectiveness, safety, and experience? 4) Can a prediction tool be devised to determine the risk of developing an ectopic pregnancy and the treatment outcome? 5) Should tests to assess whether the fallopian tubes are blocked, and are functioning, be routinely offered following treatment of tubal and interstitial ectopic pregnancy? 6) What is the emotional and psychological impact of ectopic pregnancy, and how can we address this? 7) What is the effectiveness and safety of different treatment options for less common types of ectopic pregnancy? 8) Should routine early pregnancy ultrasound scan screening be offered for people who have had a previous Caesarean section? 9) What is the effectiveness and safety of routine early pregnancy ultrasound scans as a screening tool for those at a greater risk of developing a less common type of ectopic pregnancy? 10) What is the economic cost of ectopic pregnancy? Top 10 research priorities in ectopic pregnancy research. Ajith. Top 10 priorities for ectopic pregnancy research. Fertil Steril 2025. 6 VOL. ■ NO. ■ / ■ 2025 dissemination of research priority setting studies ( 27 ). Our PSP followed this guidance to ensure the research priorities were developed using an open and transparent process. We prioritized using formal consensus development methods to ensure that the top 10 research priorities were developed using the most appropriate scientific methods. The study design, development, and delivery were also informed by a systematic review of research priority setting studies relevant to women’s health and by engaging with colleagues with sig - nificant experience in using consensus development

( 32 , 33 ). With 855 respondents from 35 countries participating in the initial survey, 413 respondents from 20 countries partici - pating in the interim prioritization survey, and 37 partici - pants from 10 countries included in the consensus development meetings, the global participation achieved in this study should secure the generalizability of the results within an international context. The study included over 800 people with lived experience of ectopic pregnancy, and they suggested potential research uncertainties during the initial survey. Their contribution was substantial throughout the study including sharing their views regarding the impor - tance of research uncertainties during the interim prioritiza - tion survey and participating fully in the consensus development meeting that prioritized the final research pri - orities. This consensus study is not without limitations. Consideration should be given to the representativeness of the study participants. A disproportionate number of re - sponses were received from participants who identified as living in Europe (495 participants, 57.9%) during the initial survey collecting possible research uncertainties. The steer - ing group devised a strategy to reach out to diverse stake - holders across different countries; however, the snowball sampling method may have influenced the demographic data accordingly. Furthermore, many participants in the study were female, which is to be expected because women are most directly affected by ectopic pregnancy, and a signif - icant proportion of women’s health clinicians are also fe - male. The initial survey (n = 553, 64.7%) and interim prioritization survey (n = 289, 70.0%) received many re - sponses from people with lived experience of ectopic preg - nancy. This demonstrates success in engaging with a stakeholder group who has not traditionally contributed to ectopic pregnancy research. However, it could potentially skew how the research uncertainties were identified and prioritized. To counteract this potential impact, the steering group convened regularly to ensure the scope and objectives of the study were adhered to in order to produce feasible and researchable results. A notable portion of respondents did not provide their characteristics, which may skew the representation of various stakeholder groups. This also highlights the limited engagement associated with web-based surveys. To partici - pate in the initial survey and interim prioritization survey, a computer or smart device and internet access were required, and thus, the findings may include more partici - pants from higher resource settings. Although the nondisclo - sure rate of demographic information is comparable to other similar studies, this could have affected the representative - ness of the sample, potentially impacting the research uncer - tainties suggested. Ectopic pregnancy and pregnancy loss are a deeply personal issue, and some participants may not have wanted identifiable data (e.g., name, country of origin, and ethnicity) in the public domain. Appreciating the sensitivity of this topic, participants were instructed that, although providing demographic information was useful, it was entirely optional. The study followed the consensus methods advocated by the James Lind Alliance and has been previously used by ten national and 2 international PSPs within women’s health ( 27 ). The thematic qualitative analysis and categorization of the initial survey data streamlined the process of formu - lating indicative research questions for the prioritization stage of the study. Although this ensured the breadth of this subject was thoroughly investigated, it could lead to the nuance of individual priorities being obscured. Meticu - lous assessment of indicative research questions was neces - sary to avoid developing broad research questions, which could be difficult to investigate, and highly specific ques - tions, which may impede prioritization by spreading a key theme over multiple research questions. Despite this rigorous process, there remains uncertainty regarding the optimal consensus development method to prioritize research uncer - tainties ( 27 ). Further methodological research is required regarding the use of different consensus methods to identify research priorities. Additional contextual information could potentially have assisted participants in prioritizing the research uncertainties. Future methodological research should determine whether additional contextual information alongside individual research uncertainties should be offered. This should include the number of people the research priority impacts upon, the feasibility of answering the research priority, and the resources required to address the research uncertainty. Reflections on the research priorities The research priorities highlight a fundamental area of research related to the understanding of the minimum stan - dard of care that people with ectopic pregnancy should expect. Establishing a clear, evidence-based standard for diagnosis, treatment, and follow-up care is critical for ensuring that people with ectopic pregnancy receive the best possible care, regardless of their location or healthcare setting ( 34–36 ). This includes determining the most effective treatment methods, including expectant, medical, and/or surgical management, and how to ensure that patients are managed in a way that improves outcomes and minimizes risks ( 37–40 ). Research should also evaluate undergraduate and postgraduate educational interventions, which could improve healthcare professional education ( 41–47 ). Healthcare professionals should be well equipped with the latest knowledge and skills to diagnose ectopic pregnancies early and accurately ( 48–52 ) and to manage treatment effectively ( 4 ). This could involve updating training programs, refining clinical guidelines, and fostering a deeper understanding of the condition across VOL. ■ NO. ■ / ■ 2025 7 Fertil Steril® primary and secondary care to improve patient satisfaction ( 53 ). Another area the research priorities highlight is the impact of ectopic pregnancy on medium- and longer-term outcomes, including future fertility and pregnancy outcomes ( 54–60 ). It is important to understand how treatment for ectopic pregnancy affects long-term reproductive health, including the risks of recurrence and the likelihood of suc - cessful future pregnancies ( 61–66 ). Research could provide invaluable information for patients, enabling them to make informed decisions about family planning after an ectopic pregnancy. The role of the fallopian tubes in future fertility warrants further exploration because tubal damage is a common cause and consequence of ectopic pregnancy ( 62 ). Evaluating whether routine testing to assess tubal patency and function should be enshrined in posttreatment care plan could help identify those at risk of subfertility or future complications. Contrary to this, the possible harm of conducting tubal patency and tubal function testing in all patients who have been diagnosed with a tubal ectopic pregnancy has not been rigorously investigated. This example demonstrates the importance of further research into this area. The research uncertainties identified have been designed to provide a broad foundation for researchers, clinicians, pa - tients, and funding bodies to consider and pursue without being too restrictive on the research agenda. A potential negative impact of this is that the feasibility of undertaking such research was not considered during the process. Conversely, we believe that these research objectives have not been previously addressed due to limited consultation with patients and limited funding in ectopic pregnancy research. Developing an international list of research prior - ities through international consensus could lay the ground - work for more international collaboration in addressing these unanswered questions in ectopic pregnancy care. The research priorities highlight the emotional and psy - chological impact of an ectopic pregnancy ( 67–70 ). The experience of an ectopic pregnancy can be deeply traumatic, often leading to feelings of grief, loss, and anxiety ( 57 , 71 ). Research focusing upon the psychological effects of ectopic pregnancy and the development of supportive care strategies would help address this aspect of recovery ( 72 , 73 ). Offering mental health support and counseling as part of a comprehensive care plan could help alleviate the emotional burden of people with lived experience of ectopic pregnancy and improve overall patient well-being ( 74–77 ). In terms of clinical outcomes, the research priorities demonstrate the need to evaluate the effectiveness and safety of different treatment options for less common types of ectopic pregnancies, such as abdominal, cervical, and inter - stitial ( 58 , 78–85 ). These rare cases present unique challenges, and there is currently limited evidence to guide management decisions ( 86 ). Understanding the best approach for managing these types of ectopic pregnancies will ensure that healthcare providers are equipped with the knowledge to provide optimal care in all ectopic pregnancy cases ( 13 , 15 , 17 , 87–94 ). Early detection is crucial for improving outcomes, particularly in individuals at higher risk ( 95–99 ). Research into the role of routine early pregnancy ultrasound scans for individuals who have had previous cesarean sections, or those with other risk factors, could enhance early diagnosis and reduce the risk of undiagnosed ectopic pregnancies ( 100–102 ). Ultrasound screening for those at higher risk of developing rarer types of ectopic pregnancy is another area of the research priorities highlighted because it could help identify problematic pregnancies earlier and allow for timely intervention ( 103 ). Understanding the economic cost of ectopic pregnancy is a vital component of future research ( 104–107 ). The direct and indirect costs of ectopic pregnancies, ranging from hospital admissions and treatments to long-term healthcare needs and lost productivity, have significant im - plications for local, regional, and national healthcare sys - tems ( 108–111 ). Research into the economic burden of ectopic pregnancy could guide resource allocation and help policymakers make informed decisions about funding and support for ectopic pregnancy care ( 112 , 113 ). Addressing these research priorities will not only improve clinical outcomes and reduce the risks associated with ectopic pregnancy but also enhance the emotional and psychological care of patients. By deepening our understanding of ectopic pregnancy and developing evidence-based approaches to treatment, healthcare providers can better support individ - uals through what is often a challenging and potentially life-changing experience. Wider context The study has developed a prioritized list of research uncer - tainties. The consensus methods have ensured that they represent the most pressing clinical needs as perceived by healthcare professionals, people with lived experience of ectopic pregnancy, and others. Funding organizations and researchers should consider these top 10 priorities for ectopic pregnancy research when setting their future research agenda. The selected list of research uncertainties should serve as a focus when making decisions regarding the alloca - tion of limited research resources. Many of the research priorities will require national and international collaboration. This is particularly true for research priorities that are related to the rarer types of ectopic pregnancy, for example, cesarean scar ectopic pregnancies. Several countries, including the United Kingdom, have developed national networks to undertake ectopic pregnancy research ( 112 ). For example, the GEM3 collaborative, based in the United Kingdom, has recently complete a multicenter randomized trial evaluating the combination of gefitinib and methotrexate to treat tubal ectopic pregnancy ( 114 ). Further development of national infrastructure in individual counties is required ( 115 ). Collaboration should spread beyond national boundaries and develop within an interna - tional setting. It is hoped that the development of a priori - tized research agenda could be an important enabler to deepen international collaboration. 8 VOL. ■ NO. ■ / ■ 2025 Development of generic infrastructure could help foster collaboration, including the use of minimum data sets, known as core outcome sets, low-cost data repositories, and standardized approaches to the reporting of research ( 115 ). A core outcome set has recently been developed for future ectopic pregnancy trials ( 116 ). Over 150 healthcare professionals, researchers, and patients have used formal consensus development methods to identify a core outcome set for ectopic pregnancy research. Consensus definitions have also been agreed for individual core outcomes, including a consensus definition for treatment success, reso - lution time of ectopic pregnancy, and adverse events. It is hoped that the core outcome set will provide a generic research tool to collect outcomes during research and stan - dardize the approach to research reporting. Research priorities identified in this study correspond with research priorities identified by the PSP for Infertility, including determining the emotional and psychological impact of infertility, investigating the modifiable risk factors that cause infertility, and identifying the optimal model of care ( 28 ). Other similarities exist when considering the research uncertainties prioritized by the PSP for Endometri - osis ( 117 ), PSP for Miscarriage ( 118 ), and International Poly - cystic Ovary Syndrome Network ( 119 ). Answering the prioritized research questions would represent a significant step forward for people with ectopic pregnancy. A blended research strategy should offer the optimal pathway to improving clinical care and patient out - comes. We recognize the important role of research that stems from fundamental science that does not have an imme - diate clinical application, intellectual curiosity of individual researchers, and research that is funded by patient organiza - tions or special interest groups. Perhaps the most important part of this process of establishing the top 10 research prior - ities for ectopic pregnancy has been strengthening the rela - tionships between partner organizations, healthcare professionals, and people with lived experience of ectopic pregnancy.

Despite the increasing prevalence of ectopic pregnancy, sig - nificant research gaps remain. The PSP has highlighted the top 10 research priorities for ectopic pregnancy, as collec - tively determined by key stakeholders. Using the rigorous James Lind Alliance methodology and with the active involvement of both patients and healthcare professionals, these research questions were crafted to directly enhance pa - tient care. Ultimately, we aim for the top 10 research ques - tions identified in this study to serve as a compelling rationale for research funding bodies to allocate resources toward the areas of most critical clinical need. CRediT Authorship Contribution Statement Tara Ajith: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investigation, Formal anal - ysis, Data curation, Conceptualization. Kurt T. Barnhart: Writing – review & editing, Supervision, Data curation. Ruth Bender Atik: Writing – review & editing, Supervision, Data curation. Tom Bourne: Writing – review & editing, Su - pervision, Data curation. Krystle Chong: Writing – review & editing, Supervision, Data curation. George Condous: Writing – review & editing, Supervision, Data curation. Pa - mela I. Causa Andrieu: Writing – review & editing, Supervi - sion, Data curation. Grigorios Derdelis: Writing – review & editing, Supervision, Data curation. Andrew W. Horne: Writing – review & editing, Supervision, Data curation. Judith A.F. Huirne: Writing – review & editing, Supervision, Data curation. Davor Jurkovic: Writing – review & editing, Supervision, Data curation. Emma Kirk: Writing – review & editing, Supervision, Data curation. Ernest H.Y. Ng: Writing – review & editing, Supervision, Data curation. Ri - cardo F. Savaris: Writing – review & editing, Supervision, Data curation. Janneke van’t Hooft: Writing – review & ed - iting, Supervision, Data curation. Madelon van Wily: Writing – review & editing, Supervision, Data curation. Liesl de Waard: Writing – review & editing, Supervision, Data cu - ration. Maria P. Velez: Writing – review & editing, Supervi - sion, Data curation. Jian Zhang: Writing – review & editing, Supervision, Data curation. James M.N. Duffy: Writing – re - view & editing, Writing – original draft, Visualization, Vali - dation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acqui - sition, Formal analysis, Data curation, Conceptualization. Maria Memtsa: Writing – review & editing, Writing – orig - inal draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investiga - tion, Funding acquisition, Formal analysis, Data curation, Conceptualization. Munira Oza: Writing – review & editing, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualiza - tion. Ben W. Mol: Writing – review & editing, Supervision, Project administration, Data curation, Conceptualization. Declaration of Interests T.A. has nothing to disclose. K.T.B. has nothing to disclose. R. B.A. reports that the Miscarriage Association National Direc - tor of this patient support organization, with no fiduciary in - terest. T.B. has nothing to disclose. K.C. has nothing to disclose. G.C. reports MRFF funding outside the submitted work and consulting fees from GE HealthCare and Samsung. P.I.C.A. has nothing to disclose. G.D. has nothing to disclose. A.W.H. reports grant funding from EU, UKRI, NIHR, CSO, Wellbeing of Women, and Roche Diagnostics outside the submitted work; lecture fees from Gedeon Richter and Ther - amex; UK Patent 2217921.1; TSC Chair for PANDA clinical trial; President-elect of the World Endometriosis Society; Co-Editor-in-Chief of Reproduction and Fertility ; Trustee and Medical Advisor to Endometriosis UK; and Specialty Advisor to the Scottish Government’s Chief Medical Officer for Obstetrics and Gynaecology. J.A.F.H. has nothing to disclose. D.J. has nothing to disclose. E.K. reports travel sup - port from Medtronics meeting on pelvic venous disorders. E. H.Y.N. has nothing to disclose. R.F.S. has nothing to disclose. J.v.H. has nothing to disclose. M.v.W. has nothing to disclose. L.d.W. has nothing to disclose. M.P.V. has nothing VOL. ■ NO. ■ / ■ 2025 9 Fertil Steril® to disclose. J.Z. has nothing to disclose. J.M.N.D. has nothing to disclose. M.M. has nothing to disclose. M.O. has nothing to disclose. B.W.M. reports research funding from Merck KGaA outside the submitted work; consulting fees from Merck KGaA, Organon, and Norgine; and travel support from Merck KGaA. SUPPLEMENTAL MATERIAL Supplemental data for this article can be found online at https://doi.org/10.1016/j.fertnstert.2025.09.032 .

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