Revised American Fertility Society Classification of Endometriosis

 

Patient Evaluation:

Inspection of the pelvis is done in an orderly (clockwise or counterclockwise) fashion, noting size, number and location of

(1) endometrial implants

(2) plaques

(3) endometriomas and

(4) adhesions.

 

Subsets for point assignment:

(1) peritoneal endometriosis

(2) left and right ovarian endometriosis

(3) obliteration of the cul-de-sac

(4) adhesions for the left and right fallopian tubes

(5) adhesions for the left and right ovaries

Peritoneal Endometriosis	< 1 cm total diameter	1-3 cm total diameter	> 3 cm total diameter
Superficial	1	2	4
Deep	2	4	6

 

where

• The serosal surface of the uterus is considered as peritoneum.

• The diameter of implants are added to give a total diameter (example given: five 0.5 cm superficial implants would have a total diameter of 2.5 cm and would be assigned 2 points).

 

Ovarian Endometriosis	< 1 cm total diameter	1-3 cm total diameter	> 3 cm total diameter
Superficial	1	2	4
Deep	4	16	20

 

where:

• diameter of implants are assessed for total diameter as described under peritoneum

• If only one ovary is present, then points applied to the remaining ovary should be multiplied by 2.

 

Posterior Cul-de-Sac Obliteration	Partial	Complete
	4	20

 

Fallopian Tube Adhesions	< 1/3 enclosure	1/3 - 2/3 enclosure	> 2/3 enclosure
filmy	1	2	4
dense	4	8	16

 

If the fimbriated end of a fallopian tube is completely enclosed, then point allocation is 16.

 

where:

• If only one adnexal structure is present, then points applied to the remaining fallopian tube should be multiplied by 2.

 

Ovarian Adhesions	< 1/3 enclosure	1/3 - 2/3 enclosure	> 2/3 enclosure
filmy	1	2	4
dense	4	8	16

 

where:

• If only one adnexal structure is present, then points applied to the remaining ovary should be multiplied by 2.

 

Scoring

 

score =

= maximum (peritoneal superficial, peritoneal deep) + maximum (left ovary superficial endometrioma, left ovary deep endometrioma)+ maximum (right ovary superficial endometrioma, right ovary deep endometrioma)+ maximum (left fallopian tube filmy adhesions, left fallopian tube dense adhesions)+ maximum (right fallopian tube filmy adhesions, right fallopian tube dense adhesions)+ maximum (left ovary filmy adhesions, left ovary dense adhesions)+ maximum (right ovary filmy adhesions, right ovary dense adhesions)

 

Interpretation

 

Score	Stage	Involvement
0	0	none
1-5	I	minimal
6-15	II	mild
16-40	III	moderate
> 40	IV	severe

 

The presence of endometriosis involving other structures (bowel, urinary tract, vagina, skin, etc.) should be noted but does not alter the assigned stage.