Classification/staging systems for endometriosis:

the state of the art

Tommaso Capezzuoli1, Sara Clemenza1, Flavia Sorbi1, Dante Campana1, Silvia Vannuccini1,2,
Charles Chapron3,4, Felice Petraglia1
1
Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44,
50134, Florence, Italy; 2 Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy; 3 Department “Development,
Reproduction and Cancer”, Institut Cochin, INSERM U1016, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; 4 Université Paris
Descartes, Sorbonne Paris Cité, Faculté de médecine, Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC),
Centre Hospitalier Universitaire (CHU) Cochin, Department of GynecologyObstetrics II and reproductive medicine, Paris, France

ABSTRACT
Study objective: To describe the types of endometriosis classifications/staging systems available in the literature and
their prognostic value.
Design: N.A.
Setting: N.A.
Patients: N.A.
Interventions: The PubMed, Medline, Embase andWeb of Science databases were searched for studies on endometri-
osis classification and staging.
Measurements and main results: Several classification/staging systems of endometriosis have been developed by
different scientific societies over the last 35 years. The ASRM, ENZIAN, and EFI classifications fulfill the basic criteria of a
clinical classification and are derived from surgical evaluation of the disease and its extension. With the exception of the
EFI, which correlates with fertility outcome, the main limitation of these classifications is their poor diagnostic and prog-
nostic value. Several newly developed staging systems based on imaging have been proposed and found to be more
correlated with infertility and surgical planning. These new classifications/staging systems should be considered in ef-
forts to develop, in the near future, an integrated evaluation of symptoms, diagnostic imaging and therapeutic approach.
Conclusions: The classification of endometriosis is an open field of clinical debate and no single system adequately
assesses and stratifies the impact of the disease on a patient’s life. The new classification/staging systems which are still
under development need to have a better prognostic value.

KEYWORDS
Endometriosis; classification; surgery; infertility; pain; pathology; diagnosis; staging.

Introduction Article history

Received 7 Dec 2019 – Accepted 14 Jan 2020
Endometriosis is one of the most common gynecological
Contact
diseases in women of reproductive age. Over the last three Felice Petraglia; felice.petraglia@unifi.it
decades, numerous basic and clinical studies have shown the Department of Experimental, Clinical and Biomedical Sciences,
complex pathogenesis of the disease, providing indications Obstetrics and Gynaecology, University of Florence, Viale Morgagni 44,
for clinical management [1,2]. Several scientific societies have 50134, Florence, Italy.
Tel: +32 27645287 - Fax: +32 27649507
developed classification systems based on the appearance and
extension of endometriosis at surgical exploration, and these
have received general consensus worldwide. They have been stromal cysts).
developed on the basis of anatomical features, while some cor- In 1949, Wicks and Larsen proposed a classification for en-
relate with infertility, aiming to be quantitative and simple tools dometriosis based on histologic features [6], whereas Huffman’s
for doctors and patients [3]. classification [7] was the first system based on surgical staging.
Sampson classified ovarian endometriosis as a subgroup Taking into consideration the localization and the extension of
of hemorrhagic cysts of the ovary, proposing an etiology for endometriotic lesions detected during surgery and pregnancy
the disease [4, 5]. Observing the histologic appearance of endo- rates, he suggested adopting a more conservative approach in
metrial-like glands and stroma in several ovarian hemorrhagic low grade stages. Later, another classification was proposed,
cysts, he added a fourth variety of ovarian hemorrhagic cysts to based on the assumption that pelvic pain was caused by older
the previously known categories (follicular, corpus luteal, and deep fibrotic lesions. According to that, the disease develops

14 Gynecological and Reproductive Endocrinology and Metabolism 2020; 1(1):14-22

 Classification of endometriosis

in three stages: (a) early development, (b) active stage, and (c) fication of endometriosis from 1949 to 2019. The search terms
relative endometrial inactivity [8]. included “endometriosis”, “staging” and “classification” in
In 1974, Mitchell and Farber developed a staging system combination with “prognostic value”, “surgery”, “infertility”,
similar to that used in gynecologic malignancies, including a “pain” and “diagnosis”. Only studies in English that were pub-
stage V for malignant transformation to adenocarcinoma. The lished as full-length articles were considered, excluding case
staging was also applied to determine whether to plan medical reports. We analyzed the titles and abstracts of the 1471 results
or surgical treatment [9]. produced by the search, selecting only articles that referred to
In same years, a new classification system was proposed surgical classifications and imaging staging systems.
dividing endometriosis into three stages: mild, moderate and
severe [10]. It was based on the principle that the success of sur-
gery in infertile women depended primarily on the severity of Classification systems
disease at the time of initial diagnosis.
In 1977, Kistner et al. [11] developed a classification system The Classification of the American Society
based on the natural history of the disease, from early perito- for Reproductive Medicine (rASRM)
neal implants to ovarian involvement, tubal-ovarian disease and The rASRM classification system is based on intraoperative
finally extension to the whole pelvis. Subsequently, Cohen pro- disease findings, and it takes into account peritoneal endome-
posed a ten-stage system based on the severity of laparoscopic triosis, ovarian endometriosis, posterior cul de sac obliteration,
findings. Extrapelvic endometriosis involvement, adenomyosis, ovarian adhesions and tubal adhesions [13]. In particular, scores
and pelvic inflammatory disease were also evaluated [5,12]. are assigned to endometriosis lesions in the peritoneum and
Since none of the previous classifications had been univer- ovaries using points that correspond to the size of the lesions.
sally accepted, in 1979 the American Fertility Society (AFS) By analogy, points are also assigned for adhesions on the ova-
generated an innovative new classification based on the use ries and Fallopian tubes. Additional points are assigned for par-
of a system of weighted values to report involvement of the tial or complete posterior cul-de-sac obliteration.
peritoneum, fallopian tubes, and ovaries. The sum of the score Finally, the assigned points are summed and a value is ob-
gave the disease stage. To facilitate the description of the im- tained, classifying the disease in one of four stages:
plants, a schematic representation of the pelvis was provided. • Stage 1 (Minimal Endometriosis): 1-5 points;
This classification was revised in 1985 and 1996, giving rise • Stage 2 (Mild Endometriosis): 6-15 points;
to the Revised American Society for Reproductive Medicine • Stage 3 (Moderate Endometriosis): 16-40 points;
score (rASRM) [13]. • Stage 4 (Severe Endometriosis): >40 points.
With respect to the rASRM, the ENZIAN staging system The rASRM endometriosis classification system is the most
(2005) added information regarding the retroperitoneal struc- widely used worldwide. For health providers, it is very easy to
tures and lesions localized in other organs [14, 15]. apply, and for patients, it is easy to understand. However, it has
Later, in 2010, a further classification system called the some limitations. In fact, it is an arbitrary scoring system based
Endometriosis Fertility Index (EFI) was developed, for pre- on subjective score allocation and it has wide score ranges be-
dicting pregnancy rates in patients with surgically documented tween the different categories. Furthermore, the stages do not
endometriosis who attempt non-IVF conception [16]. In 2012, provide any information about disease morphology. The rAS-
the American Association of Gynecologic Laparoscopists pro- RM has poor reproducibility if the disease involves the ovaries
posed a classification based on surgical difficulties, categorized and the posterior cul-de-sac. Furthermore, given the various
into four levels [17]. presentations of the disease, observer variability may be pres-
Further endometriosis classification proposals were ad- ent, leading topossible problems in documentation. The scoring
vanced by Batt et al. [18], Adamyan [19], Chapron [20], Martin system can be affected by surgical technique (laparoscopy or
[21]
, and Koninckx et al. [22]. However, endometriosis staging laparotomy) and by the timing of surgery. In addition, it does
remains an open field, especially since the last decade has not take in consideration the possible time-related evolution
brought new discoveries and insights that have changed the di- of lesions or hormonal treatments. Moreover, deep infiltrating
agnosis and treatment of endometriosis. endometriosis (DIE) and retroperitoneal structures are not ade-
The aim of the present review is to illustrate the history quately described [12, 23-25].
and the state of the art of the most widely used international There is a very poor correlation between the extent of dis-
endometriosis classifications, evaluating the strengths and lim- ease expressed by rASRM score and pain symptoms, infertil-
itations of each. In addition, considering the most recent re- ity or patient quality of life. As regards prognosis, there is no
search data, the newly proposed classification/staging systems correlation with infertility outcome and only poor predictive
are described and correlated with the most common clinical accuracy of treatment outcome.
manifestations. Therefore, the rASRM endometriosis classification system
gives poor prognostic information [12, 23-25].

Methods The ENZIAN classification

The ENZIAN classification was developed as a supplement to
The PubMed, Medline, Embase, and Web of Science data- the rASRM score, in order to provide a morphologically de-
bases were searched to identify relevant studies on the classi- scriptive classification of DIE, taking into account retroperi-

Gynecological and Reproductive Endocrinology and Metabolism 2020; 1(1):14-22 15

Petraglia F et al

toneal structures [15]. In this classification retroperitoneal struc- est prognosis and 10 the best prognosis. It is to be emphasized
tures are divided into three compartments: that the least function score is determined at completion of the
• Compartment A: vagina, recto-vaginal septum; surgical intervention, not before. It represents an estimate of
• Compartment B: uterosacral ligaments to the pelvic wall (BB: reproductive functionality after the surgical intervention. The
bilateral involvement); estimated cumulative percentage pregnant is presented graph-
• Compartment C: rectum and sigmoid colon. ically for each EFI score value. The EFI can be useful for pre-
Disease severity is classified as: dicting fertility outcome in women with previous surgical stag-
• Grade 1: invasion <1 cm; ing of endometriosis and can be useful in developing treatment
• Grade 2: invasion 1-3 cm; plans for infertile women with endometriosis. Despite showing
• Grade 3: invasion >3 cm good correlation with spontaneous pregnancy rate, it does not
Deep endometriosis invasion beyond the lesser pelvis and inva- consider uterine abnormalities, and does not correlate with pain
sion of organs are recorded separately: symptoms [4,23, 25, 29].
• FA: adenomyosis; Another consideration regarding the EFI score is that, by
• FB: bladder invasion; including infertility factors partially independent from endo-
• FU: intrinsic ureteral endometriosis; metriosis such as age, duration of infertility, and prior pregnan-
• FI: bowel disease cranial to the sigmoid colon; cy, it obviously works in infertile women, but it is difficult to
• F0: other locations. assess how much of its predictive value is related to the pres-
ence of different endometriosis forms.
The prefix “F” stands for “far” or “foreign”, referring to Table 1 shows strengths and limitations of each classifica-
distant retroperitoneal structures. tion system, considering the prognostic value of each.
The ENZIAN classification nomenclature, which is similar
to the TNM (Tumor, Lymph Nodes, Metastasis) staging system
used in oncologic diseases, is the following: A0–3 B0–3 C0–3 New perspectives: clinical staging
FA, FB, FU, FI, FO. Distant locations are only stated when of endometriosis based on imaging
present. When more than one focus is present in each compart-
ment, only the largest is evaluated. Other than those three recognized classifications there are
The ENZIAN score, describing DIE, can be considered several endometriosis staging proposals based on imaging.
complementary to the rASRM one. The advantages of the re- Transvaginal sonography (TVS) is considered the first imaging
vised ENZIAN classification are related to the precise descrip- approach for diagnosis, staging and follow-up of endometrio-
tion of involvement of retroperitoneal structures,and the fact sis. The use of ultrasound imaging has several advantages: it
that DIE lesions can be described pre-operatively. is minimally invasive, cheap, readily available and acceptable
The revised ENZIAN classification system is mainly used to women; it provides a rapid result; it is a dynamic and inter-
in German-speaking countries, but has poor international ac- active exam that makes it possible to evaluate the mobility of
ceptance. It does not take into consideration the morphological some structures and painful sites [30]. Several studies have con-
characterization of the lesions and it is more complicated, both firmed the high sensitivity and specificity of TVS in the diag-
for patients and for clinicians. With regard to prognosis, the nosis of endometrioma [31-34]. Instead, a recent Cochrane review
revised ENZIAN score has poor prognostic value in terms of showed that the sensitivity and specificity of TVS are more
course of symptoms, quality of life, and response to infertility heterogeneous in the diagnosis of DIE than in that of ovarian
or pain treatment [15, 23-27]. endometriosis: the lack of standardized definitions in the sono-
graphic classification and diagnosis of DIE is a general cause
The Endometriosis Fertility Index (EFI) for concern [35].
The EFI aims to predict pregnancy rates in patients with sur- While the importance of ultrasound in the diagnosis of
gically documented endometriosis who attempt non-IVF con- endometriosis is increasingly recognized, the challenge of
ception. The EFI is a scoring system that includes assessment developing a comprehensive and reproducible preoperative
of historical factors at the time of surgery, of adnexal function classification system for endometriosis nevertheless remains.
at conclusion of surgery, and of the extension of endometriosis. The main problem in developing an ultrasound classification
The following surgical findings are considered: the rAS- of endometriosis is the lack of a universal, systematic, evi-
RM endometriosis lesions score (i.e., not including adhesions), dence-based, and reproducible diagnostic protocol.
the total rASRM score, and a functional score determined by The International Deep Endometriosis Analysis (IDEA)
the surgeon for each of the tube, fimbria and ovary bilaterally group [36] published a consensus opinion shared by clinicians,
(normal, mild dysfunction, moderate dysfunction, severe dys- gynecological sonologists, advanced laparoscopic surgeons
function and absent or not functional).The historical factors and radiologists with an interest in endometriosis diagnosis
considered are: patient age (≤35 years old, 36-39 years old, ≥40 and management. The group proposes four basic sonographic
years old), duration of infertility (≤3 years, >3 years) and prior steps when examining women with suspected or known endo-
pregnancy (history of prior pregnancy, or not) [28,29]. metriosis, in order to systematically evaluate localization and
The surgical findings and historical factors each give a extension of ectopic endometrial lesions:
score. The two scores are summed to obtain the EFI score. The 1. Routine evaluation of the uterus and the adnexa reporting the
EFI score ranges from 0 to 10, with 0 representing the poor- possible presence of adenomyosis and endometrioma

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 Classification of endometriosis

Table 1 Strengths, limitations and prognostic value of endometriosis classification systems (rASRM, ENZIAN, EFI.

STRENGTHS LIMITATIONS PROGNOSTIC VALUE

Most widely used classification in the world Arbitrary scoring system No correlation with symptoms, quality of life
Easy to use Wide score ranges between categories and infertility
Simple for patients to understand No information about disease morphology No correlation with infertility outcome and with
treatment outcome
Poor reproducibility in involvement of ovaries
and pouch of Douglas
Observer error may be present
rASRM Can be affected by surgical technique and
timing of surgery
Limited reproducibility
Does not consider disease evolution or
hormonal treatment
Poor description of deep infiltrating
endometriosis and retroperitoneal structures

Precise description of retroperitoneal structures Poor international acceptance Poor correlation with symptoms, quality of life
and possibility of pre-operative evaluation of No morphological characterization of lesions and infertility
deep infiltrating endometriosis Poor correlation with infertility outcome and
ENZIAN Difficult to understand for clinicians and
patients with treatment outcome
Scarcity of international research

Useful in developing treatment plans for Does not consider uterine abnormalities Useful to predict fertility outcome in women
EFI infertile women with endometriosis with previous surgical staging of endometriosis
Does not correlate with pain symptoms

2. Evaluation of transvaginal sonographic “soft markers” (site- The Endometriosis Surgical-Ultrasonographic System
specific tenderness and ovarian mobility) (ESUS) [40] is a preoperative mapping of endometriosis, de-
3. Assessment of the status of the pouch of Douglas (POD) us- veloped to record the location, size, and depth of lesions vis-
ing the real-time TVS-based ‘sliding sign’ ualized preoperatively by TVS and subsequently confirmed
4. Assessment for DIE nodules in the anterior and posterior by laparoscopy and histology. The ESUS was compiled by
compartments. marking the location of pelvic endometriosis divided into four
A possible limitation is the operator’s experience, especial- compartments (adnexal, anterior, posterolateral, and Douglas)
ly in evaluating the sliding sign to predict POD obliteration and by selecting, for each lesion, the corresponding box op-
and the severity of deep pelvic disease. Experienced operators tion of ‘‘yes-no’’,also adding the relative diameter and depth of
who have performed more than 2500 scans reach proficiency in infiltration. The authors reported variable diagnostic accuracy,
the detection of rectal DIE nodules and POD obliteration using ranging from 76 to 97% depending on the anatomical site: the
TVS after approximately 40 examinations [37, 38]. lowest accuracy (59%) was obtained in the diagnosis of vag-
Coccia et al. [39] proposed a staging system of DIE based on inal endometriosis, whereas the greatest accuracy (97%) was
the evaluation of five components: shown in detecting bladder lesions and Douglas obliteration.
1. Location (anterior, posterior, or lateral compartments); The ESUS systematic evaluation of the different pelvic sites
2. Size (longitudinal, anteroposterior and transversal axes of is an easy process for both ultrasonographer and surgeon. The
the implants); main limitation of this study was the high prevalence of DIE,
3. Shape: nodules (solid hypoechoic nodule with a rounded representing a possible source of bias, due to the patient selec-
shape), linear thickening (abnormal hypoechoic linear thick- tion in three endometriosis referral centers.
ening), or plaques (hypoechoic areas with irregular shape); Menakaya et al. [41] developed the ultrasound-based endo-
4. Symptoms aroused during the exam:none (0), mild (1–3), metriosis staging system (UBESS), a score designed to predict
moderate (4–6), and severe (7–10); the level of complexity of laparoscopic surgery for endometri-
5. Infiltration of the bowel wall. osis, in order to facilitate referral of women with higher-stage
The authors also evaluate the presence of monolateral or endometriosis to tertiary laparoscopic centers. Used for TVS
bilateral ovarian endometrioma, kissing ovaries, adenomyosis, examination, this ultrasound-based approach consisted of(42):
and fixity of organs, as well as the urinary tract. The main lim- 1. routine assessment of the uterus and ovaries,
itation of this system is the difficulty in evaluating symptoms: 2. tenderness-guided assessment of the pelvis
in fact, the perception of pain might vary from individual to 3. assessment of organ mobility including assessment of ovari-
individual and in the same individual; the pain depends on the an mobility (IIIa) and assessment of POD status (IIIb)
pressure exerted by the examiner with the probe and it is diffi- 4. assessment of anterior, lateral, and posterior pelvic compart-
cult to identify which lesion/s is/are responsible for pain in the ments for non-bowel DIE
case of multiple lesions. 5. assessment of the anterior wall of the bowel for bowel DIE.

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Petraglia F et al

Based on the ultrasound data from this five-domain model, symptoms, in particular dysmenorrhea, cyclic and non-cyclic
the authors developed their three-stage preoperative UBESS pelvic pain, deep dyspareunia, and cyclic intestinal and urinary
using the Royal College of Obstetricians and Gynaecologists symptoms [48].
recommendations on the stratification of complexity of laparo- In 1996, Vercellini et al. [49] correlated pain symptoms,
scopic procedures [43]. UBESS stage I (UBESS I) predicts mild measured by visual analog scale, to rARSM stage. The authors
disease and the need for a level 1 trained laparoscopic surgeon. did not find any correlation with acyclic pelvic pain, deep dys-
UBESS stage II (UBESS II) predicts moderate endometriosis pareunia and dysmenorrhea. Similar results were detected by
and the need for a level 2 trained laparoscopic surgeon, while the same group in 2006, with the exception of acyclic pelvic
UBESS stage III (UBESS III) predicts higher stage (severe) pain, which was significantly associated with severe stage of
disease and the need for a level 3 trained laparoscopic surgeon. endometriosis [50]. In 2013, to confirm whether the revised EN-
UBESS showed an accuracy of 84.9% in predicting the exact ZIAN classification correlates with clinical symptoms, espe-
level of laparoscopic surgery and performed best in predict- cially with pain, Haas et al. [51] performed a prospective study.
ing severe endometriosis. The main limitations of UBESS is They found that ENZIAN correlated partially with clinical
that it was developed and applied retrospectively and has been symptoms, in particular lesions in compartment A with abdom-
applied in women with a high prevalence of endometriosis re- inal pain and lesions in compartment C with bowel symptoms.
ferred to tertiary centers with high experience in endometriosis Moreover, abdominal pain and dysmenorrhea seem to be
ultrasound diagnosis. correlated with the higher stages of the disease [26]. Although
Magnetic resonance imaging (MRI) is a reliable preoper- the ENZIAN classification system might correlate with pain
ative diagnostic procedure that allows both localization of en- and dysmenorrhea, it does not consider the level of pain.
dometriosis lesions and planning of the surgical procedure, in
particular for DIE. International consensus reports regarding Infertility
preoperative MRI diagnostic protocols in DIE are sparse. Although the rAFS is the most widely used staging system for
Zanardi et al. [44] proposed a staging of pelvic endometriosis endometriosis, it does not provide a good characterization of
based on MRI features, and compared it with the AFS laparo- disease severity and pregnancy outcome [52]. The EFI ist he
scopic classification. The MRI score was based on size, edges, only classification system to predict pregnancy rate (PR) after
wall thickness, septations, signal intensity on T2-weighted im- surgery in endometriotic infertile patients. This index has been
ages of endometriomas, and presence of pelvic implants. This validated as clinically useful among patients with surgically
score classifies endometriosis in four classes, comparable with confirmed endometriosis who wish to become pregnant and
those of AFS laparoscopic staging. There was agreement be- has been validated externally in populations of infertile patients
tween the MRI and AFS classification in 33/35 patients, and with endometriosis after surgery.
thus only two cases of discordance. Two other studies [45, 46] The EFI score was derived from a cohort of 579 patients
compared preoperative MRI features with intraoperative sur- and then prospectively tested in 222 patients, confirming that
gical results in patients with DIE using the ENZIAN score and it predicts PR after endometriosis surgical staging [29]. Other
found an excellent correlation with the intraoperative findings. studies designed to validate the EFI score have been published
However, standardization of MRI protocols used in the detec- since the original article by Adamson.
tion of DIE will be a crucial step towards increased diagnostic Wei et al. [53] carried out an external retrospective validation
validity. in 350 patients. The authors found a significant association be-
Recently, a preoperative score based on TVS and MRI tween a high EFI score and the probability of conceiving spon-
showed good accuracy in predicting the risk of recto-sigmoid taneously within 3 years (71.8% for scores of between 8 and 10
endometriosis [47]. versus 44.4% for scores of between 5 and 7). However, the arti-
The development of an imaging classification of endome- cle was published in Chinese and the limited number of women
triosis is a possible future perspective. However, a universally with a score of between 0 and 4 limits the validity of the results.
accepted diagnostic protocol would be necessary in order to Tomassetti et al. conducted a retrospective cohort study in
map the disease, triage women to different forms of treatment, which the EFI was related to pregnancy outcomes in 233 wom-
andfollow up the lesions. Furthermore, a shared protocol would en attempting non-assisted reproductive technology (non-ART)
help in evaluating the efficacy of a medical treatment, in iden- conception immediately after surgery. A significant relation-
tifying sites of the disease that could involve surgical risks and ship was found between the EFI score and the time to sponta-
thus require a multidisciplinary approach, and in producing a neous pregnancy. For each increase of 1 point in the EFI score,
standardized method and language for scientific groups. the relative risk of becoming pregnant increased by 31%. The
average EFI score in their study was 8, reflecting a population
with a good prognosis. Therefore, these results do not allow
Prognostic value of endometriosis any conclusions to be drawn about bad prognosis groups [28].
classifications/staging systems for The same authors, in another study, recently confirmed the high
painful symptoms, infertility and surgical reproducibility of the EFI, supporting its use in daily clinical
planning practice as the principal clinical tool for postoperative fertility
counselling and management of women with endometriosis [54].
Painful symptoms Boujenah et al. [55] also demonstrated external validation of
Endometriosis is typically characterized by several painful the EFI, in 420 infertile and endometriotic patients after lapa-

18 Gynecological and Reproductive Endocrinology and Metabolism 2020; 1(1):14-22

 Classification of endometriosis

roscopic surgery. The authors found that patients with high EFI not be achieved, with clinically-significant uterine pathology
scores had significantly higher non-ART PRs compared with including leiomyomas, adenomyosis, intrauterine adhesions
patients with low EFI scores after 12 months of follow-up. or congenital anomalies, or those having repeat surgery, have
Moreover, non-ART PRs were significantly higher for patients poorer prognosis. Therefore, these factors can be used to fur-
with complete endometriotic lesion removal (ablation, resec- ther guide management decisions, especially in the presence of
tion, or excision and adhesiolysis) compared with patients with an intermediate EFI, for individualization of care [58].
incomplete removal. These data underline the importance of
surgical results. The strategy of removing as much endome- Surgical planning
triotic tissue as possible and then referring patients for ART if Considering the high complexity of endometriosis surgery,
they failed to conceive spontaneously within 12 months after careful preoperative planning of the treatment is essential. The
surgery led to an overall PR (surgery and ART treatment) of ENZIAN classification provides good information about mor-
78.8%. A 2015 Italian study also found a significant association phological characteristics of lesions, the side and localization
between the probability of pregnancy and the EFI score in a of DIE lesions, and the involvement of retroperitoneal struc-
series of 104 patients [56]. tures [11].
Li et al. [57] conducted a retrospective study enrolling 345 Haas et al. [27], in 2013, developed a model for preoperative-
endometriosis-related infertile women after laparoscopic sur- ly predicting surgical difficulty on the basis of on the ENZIAN
gery. Significant differences in spontaneous PRs between dif- system. Using multiple regression analysis, they developed a
ferent EFI scores were identified: the higher the EFI score, the model for estimating the operation time in minutes, assuming
better the chances of spontaneous pregnancy. In particular, in complication-free procedures. The estimated operating time is
women with an EFI score of 4 or less, the spontaneous PR calculated in minutes by adding the constant (intercept) and
was very low. Therefore, to achieve a higher PR, the authors regression coefficients of the relevant ENZIAN classifications.
suggest that in vitro fertilization and embryo transfer should This formula can be used for both single and combined lesions.
be recommended inpatients with an EFI score ≥5 at12 months Considering this model, a small lesion of the uterosacral liga-
from surgery. ments (B1, BB1) does not significantly alter the operating time,
Finally, Maheux-Lacroix et al. [58] performed a retrospec- whereas lesions with horizontal extension (B2, BB2, BB3) of-
tive study of 235 women attempting pregnancy after resection ten require often ureterolysis and the procedure is longer, espe-
of moderate-severe (Stage III–IV) endometriosis. They found cially in the case of bilateral involvement. With regard to bowel
that a higher EFI was associated with better fertility prognosis: endometriosis, small intestinal foci (C1) do not always require
for women with an EFI of 0–2 the estimated cumulative non- a complete bowel resection. In the case of C2 and C3 lesions
ART live birth rate at five years was 0% and steadily increased the operating time is longer, while there is no major surgical
up to 91% with an EFI of 9–10, while the proportion of wom- time difference if the intestine is resected for a 1-3 cm endome-
en who attempted ART and had a live birth steadily increased triotic nodule (C2) or for a larger nodule (>3 cm).
from 38 to 71% among the same EFI strata. Considering this model, the ENZIAN score is useful not
Use of the EFI score seems valuable, allowing non-ART only as a supplement to the rASRM score; indeed, it is also
procreation to be considered in cases with a high score, and, highly suitable for precise planning of surgical management
especially, allowing patients with the most unfavorable prog- and for informing DIE patients regarding the planned operat-
nosis after surgery to be more quickly oriented towards ART. ing time.
Data suggest that it is not the severity of endometriosis based TVS can be useful in pre-surgical evaluation in order to
on rASRM stage that is of primary importance in predicting plan the intraoperative management of patients with endome-
pregnancy, but rather adnexal involvement, including ovarian triosis, giving a good prognosis of the surgical difficulty. In
disease and extensive endometriosis. The least function score particular, with ESUS, Exacoustos et al. [40] created an accurate
(the sum of those scores determined intraoperatively after sur- preoperative mapping of pelvic endometriosis lesions using
gical intervention that describes the function of the tube, fim- TVS. The authors demonstrated that pre-surgical evaluation
bria, and ovary on both sides) seems to be the main significant performed by an expert sonographer using ESUS shows elevat-
contributor to the prediction of spontaneous pregnancy among ed accuracy in DIE diagnosis and characterization. It is useful
all the factors involved in the EFI score [28, 55, 57, 58]. The EFI for evaluating the presence and localization of DIE, helping the
takes into account surgical findings both pre-surgery (ASRM surgeon in the planning of endometriosis surgery (surgical ap-
scores, essentially amount of disease) and post-surgery (least proach, involvement of other specialists, communication with
function score, essentially functional capacity post-resection), the patient, management of disease). Similarly, UBESS staging
and also historical factors including age, duration of infertility, is useful for predicting the level of complexity of laparoscopic
and pregnancy history. However, the EFI has some limitations. surgery for endometriosis, in order to facilitate the referral of
Although age is included in the calculation of the EFI score, the women with higher-stage endometriosis to tertiary laparoscop-
ovarian reserve is not taken into account. In addition, the EFI ic centers [41].
score does not include severe uterine abnormality and adeno- Finally, the ENDORECT score [47] is a simple preoperative
myosis. Finally, the EFI does not consider other possible mech- score based on MRI and TVS that predicts the risk of recto-sig-
anisms of infertility in cases of endometriosis (peritoneal, folli- moid endometriosis.
cular, implantation disorders),beyond tubal-ovarian alterations. The score is based on four simple preoperative YES/NO
Women in whom complete resection of endometriosis could items: palpation of a posterior nodule on digital examination, a

Gynecological and Reproductive Endocrinology and Metabolism 2020; 1(1):14-22 19

Petraglia F et al

UBESS score of 3 on TVS, rectosigmoid infiltration on MRI, of the available evidence. However, to become popular and be
and the presence of blood in the stools during menstruation. used worldwide, a classification system should be simple, rapid
The score results in three recto-sigmoid endometriosis risk to use, and inexpensive; it should also demonstrate internal and
groups (high, intermediate and low) with good accuracy. external validity.
Endometriosis surgery needs an adequate classification More importantly, any system must demonstrate internal
system for use in pre-operative planning of the treatment and and external validity in populations with pain, infertility, or
in informing patients. Among the existing classifications, only both, and this is not the case with any of the currently available
the ENZIAN score can contribute to pre-surgical evaluation of systems. Developing such a classification therefore seems to be
the operating time, based on the dimension and localization of a very, very difficult task, and only an international initiative
the lesions. TVS can add information about the presence and might have some chance of succeeding.
localization of DIE and, if combined with MRI, can predict the It is not possible to design a reliable classification of a dis-
presence of recto-sigmoid endometriosis. ease with unknown etiology and natural history, inconstant as-
sociations with infertility and pain, and variable response to
medical and surgical treatment.
Conclusion This review has evaluated the internationally accepted en-
dometriosis classifications, focusing on the advantages and dis-
The present analysis confirms that we have a great collec- advantages of each. Its major strength is that it lists, in a simple
tion of classification systems for endometriosis. The use of manner, all the most used endometriosis classification systems,
a toolbox for surgical classification of endometriosis that in- highlighting the prognostic value of each and identifying the
cludes the rASRM, ENZIAN and EFI staging systems has been situations in which they are applicable or not.
also proposed, giving a picture of the surgically treated patient In conclusion, the existing classification systems of endo-
and prognosis for desire of pregnancy [23]. metriosis were very useful in the past, but scientific and clinical
From the overall evaluations it is clear that, with the ex- information on the disease has now increased, modifying the
ception of the EFI which correlates with fertility outcome, the management of these patients. Therefore, a new classification
main limitation of current classifications is their poor prog- system with better prognostic values across all types of patients
nostic value. In fact, in the last two decades it has become with endometriosis is warranted.
clear that: a) endometriosis is a chronic inflammatory disease
[59]
; b) menstrual-related pain is a critical symptom and is not
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Conflicts of interest: none

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