Ectopic pregnancy was frequently fatal before the advent of surgical intervention. For many years, salpingectomy was the standard approach. Later, in an effort to preserve future fertility, salpingostomy was introduced in cases without extensive tubal damage. More recently, medical management of ectopic pregnancy with methotrexate has proven efficacious in carefully selected unruptured ectopic pregnancies. Often forgotten, however, is that before the advent of surgical therapy it was noted that ectopic pregnancy was not uniformly fatal and that some patients had spontaneous resolution of the ectopic gestation, either through spontaneous regression or tubal abortion. This fact led certain physicians to attempt purposeful expectant management of ectopic pregnancies. Their studies have helped define which patients are likely to benefit from this strategy. We review the published studies that describe the expectant management of ectopic pregnancy and provide guidelines to assist clinicians in choosing this approach to treatment.