Fertility Institute of the Mid-South
Research and Education in Reproductive Endocrinology and Surgery


1988 Endo Slides
1990 Endo Color Atlas
1991 Endo Lecture Slides
Fertility Surgery

Dr. Dan C. Martin's
Clinical Practice is at:
UT Medical Group, Inc.
7945 Wolf River Blvd
Suite 320
TN 38138
Phone (901) 347-8331
Fax (901) 347-8188



Endometriosis Staging and Classifications


Endometriosis staging, classification, diagnosis and definition has many approaches since Lockyer's classification in 1917.  The page summarizes the findings of some of those systems.

Lockyer 1917

Cuthbert Lockyer of Samaritan Hospital for Women and Charing Cross Hospital, UK, published A New Classification of Adenomyoma In his book "Fibroids and Allied Tumors" in 1918.  This was a classification of the anatomic location of adenomyomas (endometriosis).

Acosta 1973

Acosta, Buttram, Besch, Malinak, Franklin and Vanderheyden published A Proposed Classification of Pelvic Endometriosis in Obstetrics and Gynecology, Volume 42, pages 19 to 25, 1973.

AFS 1979

The original American Fertility Society Classification of Endometriosis is in Fertility and Sterility Volume 32, pages 633 to 634, 1979.

rAFS 1985

The Revised American Fertility Society Classification of Endometriosis is in Fertility and Sterility Volume 43, pages 351 to 352, 1985.

Batt 1989

Ronald Batt published a grading system to address the level of certainty of the histological diagnosis of endometriosis in 1989 .  This seeks to establish a difference between a diagnosis based on possible findings and those with definitive findings.  This was revised in a 2003 article in the Journal of Pediatric and Adolescent Gynecology.

Batt Grade 1: possible residua of resorbed endometriosis, i.e., hemosiderin, calcium, nerve, blood vessels, and smooth muscle.

Batt Grade 2: consistent with endometriosis, i.e., hemosiderin, characteristic glands, or stroma.

Batt Grade 3: definite endometriosis, i.e., characteristic glands and stroma with hemosiderin.

Batt Grade 4: grade 3 with structures conveying an organoid pattern, i.e., glandular-stromal layer overlying well-developed smooth muscle layer.  This has a grossly identified structure suggesting a small uterus.

Batt RE, Smith RA, Buck GM, et al: A case series -- peritoneal pockets and endometriosis: rudimentary duplications of the Mullerian systemAdolesc Pediatr Gynecol 2:47, 1989

Batt R, Mitwally MF. Endometriosis from thelarche to midteens: pathogenesis and prognosis, prevention and pedagogyJ Pediatr Adolesc Gynecol 16:333-347, 2003.  The 2003 paper can be purchased from Elsevier Science Direct.

Adamyan 1993

Leila Adamyan published a classification of retrocervical endometriosis in Obstetric and Gynecologic Surgery edited by David Nichols in 1993. This classified endometriosis according to the extent of disease in the retrocervical area. This are is also called the rectovaginal Pouch of Douglas and the posterior cul-de-sac.

Adamyan Stage I: Endometriotic lesions are confined to the rectovaginal cellular tissue in the area of the vaginal vault.

Adamyan Stage II: Endometriotic tissue invades the cervix and penetrates the vaginal wall, causing fibrosis and small cyst formation.

Adamyan Stage Ill: Lesions spread into the sacrouterine ligaments and the rectal serosa.

Adamyan Stage IV: The rectal wall, rectosigmoid zone, and rectouterine peritoneum are completely involved, and the rectouterine pouch is totally obliterated.

Adamyan L. Additional international perspectives. In: Nichols DH, ed.  Gynecologic and Obstetric Surgery.  St. Louis: Mosby Year Book,  pages1167-1182, 1993

The Adamyan Classification was the basis for:

Retrocervical and Rectovaginal Endometriosis

Distribution of Rectovaginal Endometriosis and

Martin and Batt 2001 listed below

rASRM 1996

The Revised American Society for Reproductive Medicine classification of endometriosis: 1996 is in Fertility and Sterility Volume 67, pages 817 to 821, 1996.  The classification pages are at Classification. The complete article can be purchased from Elsevier Science Direct.

This republication of the  Revised American Fertility Society classification of endometriosis: 1985 (rAFS) was after the organization changed it's name. Although the 1985 version did not produce a dose-response relationship, the 1996 version did not make arbitrary changes in rAFS, which provides a means of clearly documenting extent and location of disease.  The 1996 version adds instruction and illustrations.  5 of the 8 illustrations are from Dr. Martin (this site) and 4 are found in the Laparoscopic Appearance of Endometriosis Color Atlas, 1990.  This is in a low resolutionPDF at Color Atlas LAE 1990.

Martin and Batt 2001

Martin and Batt updated and discussed the anatomy and implications of  Adamyan's classification of retrocervical endometriosis.

Martin DC and Batt RE.  Retrocervical, Rectovaginal Pouch and Rectovaginal Septum Endometriosis.  J Am Assoc Gynecol Laparosc 8: 12-17, 2001

Adamson 2002

Adamson GD, Pasta DJ. Pregnancy rates can be predicted by validated endometriosis fertility index (EFI). Fertil Steril 77 (2) (suppl 1) : s48, 2002

The EFI ranges from 0 to 10 with 0 representing the poorest prognosis and 10 the best prognosis. The estimated cumulative percent pregnant based on the EFI score demonstrates the utility of the EFI. Results of correlation analysis showed a good correlation of predicted and actual outcomes in the prospectively validated patients for all stages of endometriosis.

Chapron 2003

Professor Charles Chapron is at the Service de Chirurgie GyneÂcologique, Clinique Universitaire Baudelocque, 123, Boulevard Port-Royal, CHU Cochin±Saint Vincent de Paul, 75014 Paris, France.  Professor Chapron published Anatomical Distribution of Deeply Infiltrating Endometriosis: Surgical Implications and Proposition for a Classification in Human Reproduction Volume 18 pages 157 to 161, 2003.  This classification is particularly concerned with deeply infiltrating endometriosis (DIE) as cause of pain.

Chapron C, Fauconnier A, Vieira M, Barakat Dousset HB, Pansini V, Vacher-Lavenu MC, Dubuisson JB.  Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification.  Human Reproduction 18:157-161, 2003.

Tuttlies, Keckstein, Ulrich, 2005

Tuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW, Wustlich M, Buchweitz O, Greb R, Kandolf O, Mangold R, Masetti W, Neis K, Rauter G, Reeka N, Richter O, Schindler AE, Sillem M, Terruhn V, Tinneberg HR.  ENZIAN-score, a classification of deep infiltrating endometriosis [Article in German].  Zentralbl Gynakol. 2005 Oct;127(5):275-81.

Martin 2006

Dr. Dan Martin proposed  preliminary considerations for 2 grading system to address the level of certainty of the laparoscopic diagnosis of endometriosis, similar to Batt above, is needed.  [ASRM 2006]   [PDF of Poster

The following include recent revisions to the suggestions on the poster:

Laparoscopic Grades of Certainty (4 Grades)

Grade 1: Possible endometriosis - Peritoneal vesicles, red polyps, yellow polyps, hypervascularity, scar, adhesions. 

Grade 2: Suggestive of endometriosis - Chocolate cyst with free flow of chocolate fluid.

Grade 3: Consistent with endometriosis - Dark scarred (puckered pigmented or mixed color) lesions, red lesion on fibrous scarred background, chocolate cyst with mottled red and dark areas on white background.

Grade 4: Endometriosis - Dark, scarred (or puckered, pigmented) lesions at first surgery.

Laparoscopic Grades of Certainty (Simpler version)

Probable Endometriosis - A peritoneal, retroperitoneal, diaphragmatic or other red or dark lesion associated with a white, scarred perimeter or a chocolate cyst with mottled red and dark areas on white background. 

Abnormal Peritoneal Lesion - Any peritoneal, retroperitoneal, ovarian, diaphragmatic, scar or other abnormality not classified as “Probable Endometriosis.”

Martin DC.  Applying STARD criteria to the laparoscopic identification of endometriosis. (abstract).  Fertil Steril 86 (supplement 2): s270, 2006

Adamson 2008

Adamson GD.  Endometriosis Fertility Index (EFI): The New, Validated Endometriosis Staging System.  AGES XVII Annual Scientific Meeting and WCE 2008 Art & Science of Endometriosis.  Melbourne, Australia, 11-14 March, 2008. Poster # 33, Abstract page 72

The 2002 EFI was previously developed retrospectively and is now validated prospectively.  This is accepted for publication in Fertility and Sterility as of 8/26/09 and is expected to b at by mid-September, 2009.

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