Comparative efficacy of tube-sparing interventions for tubal ectopic pregnancy: a systematic review and network meta-analysis.

AIM: To compare the efficacy, safety, and reproductive outcomes of tube-sparing interventions for tubal ectopic pregnancy (TEP).

METHODS

PubMed, Web of Science, CENTRAL, and Embase were searched from inception to June 2026 for randomized controlled trials. The protocol was registered in PROSPERO (CRD420261429862), and reporting followed PRISMA-NMA guidance. A frequentist random-effects network meta-analysis was performed. The primary outcomes were treatment success and failure rates. Secondary outcomes included time to hormone normalization, re-injection rate, adverse events, and subsequent natural intrauterine pregnancy rate.

RESULTS

Thirty-five randomized trials involving 3,211 patients and 11 interventions were included. For treatment success, most interventions did not differ significantly from single-dose methotrexate (MTX). Expectant management showed a lower success rate (RR 0.79, 95% CI 0.68-0.93). Salpingotomy plus MTX ranked highest for success (SUCRA 91.0%), but the effect estimate was not statistically significant versus single-dose MTX (RR 1.17, 95% CI 0.98-1.40). For treatment failure, expectant management increased failure risk (OR 3.33, 95% CI 1.09-10.13), whereas salpingotomy reduced it (OR 0.26, 95% CI 0.08-0.85). Multi-dose MTX increased adverse events (OR 1.63, 95% CI 1.18-2.24). No significant differences were observed in subsequent natural intrauterine pregnancy.

CONCLUSION

Most tube-sparing strategies did not improve treatment success over single-dose MTX. Salpingotomy may reduce treatment failure, whereas expectant management carries higher failure risk. Multi-dose MTX requires caution because of increased adverse events.