Is there a stage 5 endometriosis?
One answer is that Canis (1992) suggested using a
revised American Fertility Society (rAFS, 1985) score of
>70 as a new stage 5 for endometriosis. This is also the
4B sub-score of the Endometriosis Fertility Index (EFI)
David Adamson's 2010 EFI is a clinical tool used to predict
pregnancy rates after endometriosis surgery. It is the
only system that is predictive of fertility, but is not a
staging system. The EFI has 6 levels and uses the 1985
rAFS staging system’s total and endometriosis sub-total
score separately. The EFI is based 50% on history (20%
on age, 20% on years of infertility & 10% on pregnancy
history), 30% on surgical findings at the completion of
surgery, and 20% on the rAFS scores (10% on the
endometriosis sub-total score and 10% on the total score
that includes adhesions).
The 1984 rAFS staging system was renamed the revised
American Society of Reproductive Medicine (rASRM)
staging system when that organization changed their
name. The rASRM endometriosis staging system is the
same as the rAFS endometriosis staging system.
The rAFS (or rASRM) is the staging system most
commonly used at surgery, but is not predictive of
fertility. It can be used to describe the appearance at
surgery and is somewhat predictive of surgical difficulty.
The rAFS has 150 points. A score 40 or higher is rASRM
stage 4. The EFI separates stage 4 into scores for 4A (40
to 70 points) and 4B (71 to 150 points). Scores of 71 and
higher are generally seen only with severe adhesions.
Adhesions, a type of scar tissue, can block the pathway
that the eggs use to get to the tube.
If your physician does not use the EFI, then you can use
the following for an approximate score. Note that high
scores are good.
1. Calculate your historical factors score using the sum of
the 3 historical factors.
Through age 35 years - 2 Points
36 to 39 years - 1 Point
40 years or older - 0 Points
Years of Infertility
Infertility up to 3 years - 2 Points
Infertility greater than 3 years - 0 Points
Yes - 1 Point
No - 0 Points
2. Calculate your Surgical Factors score by comparing
your understanding of your surgery to the following
possibilities. If you have more than one answer, use both
your highest and lowest estimates to see how those
change the pregnancy rate projection on the Estimated
Percent Pregnancy figure below.
- 5 points for mild endometriosis and healthy tubes with
- 4 points for moderate endometriosis with healthy tubes
and with all endometriosis and all adhesions removed
- 3 points for moderate endometriosis with mildly
damaged tubes and all endometriosis and adhesions
- 2 points for severe endometriosis with healthy tubes, no
large endometriomas and all adhesions removed
- 1 points for severe endometriosis with large
endometriomas, mildly damaged tubes and most
- 0 points for severe endometriosis, severe tubal damage
and large endometriomas with many adhesions remaining
3. Add the totals for your historical factors score and your
surgical factors score for a total. Compare the total with
the estimated percent pregnancy below.
EFI Score Pregnant Pregnant
at 1 year at 3 years
9-10 67% 75%
7-8 39% 66%
6 30% 54%
5 27% 42%
4 15% 28%
0-3 10% 10%
Adamson GD & Pasta DJ. Endometriosis fertility index:
the new, validated endometriosis staging system Fertil
American Fertility Society. Revised American Fertility
Society classification of endometriosis 1985. Fertil Steril
American Society for Reproductive Medicine
classification of endometriosis: 1996. Fertil Steril 67(5):
Canis M, Pouly JL, Wattiez A, et al. Incidence of bilateral
adnexal disease in severe endometriosis (revised
American Fertility Society [AFS], stage IV): should a
stage V be included in the AFS classification? Fertil Steril