Journal of the European Society for Gynaecological Endoscopy


Endometriosis classification systems: an international survey to map current knowledge and uptake

International Working group of AAGL, ESGE, ESHRE and WES, K.T. Zondervan, S. Missmer, M.S. Abrao, J.I. Einarsson, A.W. Horne, N.P. Johnson, T.T.M. Lee, J. Petrozza, C. Tomassetti, N. Vermeulen, G. Grimbizis, R.L. De Wilde


Endometriosis, infertility, classification, staging, reporting, survey, revised American Society for Reproductive Medicine, endometriosis fertility index, ENZIAN


Background: In the field of endometriosis, several classification, staging and reporting systems have been developed and published, but there are no data on the uptake of these systems in clinical practice.

Objectives: The objective of the current study was to examine whether clinicians routinely use the existing endometriosis classification systems, which system do they use and what are the clinicians’ motivations?

Materials and Methods: A cross-sectional study was performed to gather data on the current use of endometriosis classification systems, problems encountered and interest in a new simple surgical descriptive system for endometriosis. Of particular focus were three systems most commonly used: the Revised American Society for Reproductive Medicine (rASRM) classification, the Endometriosis Fertility Index (EFI), and the ENZIAN classification. Data were analysed by SPSS. A survey was designed using the online SurveyMonkey tool consisting of 11 questions concerning three domains— participants’ background, existing classification systems and intentions with regards to a new classification system for endometriosis. Replies were collected between 15 May and 1 July 2020.

Main outcome measures: Uptake, feedback and future intentions.

Results: The final dataset included the replies of 1178 clinicians, including surgeons, gynaecologists, reproductive endocrinologists, fertility specialists and sonographers, all managing women with endometriosis in their clinical practice. Overall, 75.5% of the professionals indicate that they currently use a classification system for endometriosis. The rASRM classification system was the best known and used system, the EFI system and ENZIAN system were known by a majority of the professionals but used by only a minority. The lack of clinical relevance was most often selected as a problem with using any system. The findings of the survey suggest that clinicians worldwide are open to using a new classification system for endometriosis that can achieve standardised reporting, and is clinically relevant and simple.

Conclusions: Even with a high uptake of the existing endometriosis classification systems (rASRM, ENZIAN and EFI), most clinicians managing endometriosis would like a new simple surgical descriptive system for endometriosis.

What is new? The findings therefore support future initiatives for the development of a new descriptive system for endometriosis and provide information on user expectations and conditions for universal uptake of such a system.