Applying the new endometriosis classification in a theatre setting Danie Botha FEMBRYO Fertility and Gynaecology Clinic Port Elizabeth UCT Postgraduate Refresher Course 2015

Purpose of a classification system For any disease state to be grouped, staged or classified, a classification system needs to be in place. Classification schemes should be such that similar disease stages have similar , predictable outcomes in response to treatment. In the case of endometriosis, it should be used as an expert system in order to provide guidelines for treatment and prognosis for post –treatment fertility, relief of pelvic pain and recurrences.

Although several classifications have been defined over the years, the perfect system still does not exist. As with other classification systems, the objectives of a classification for endometriosis should be: 1. to identify certain characteristics of the disease that will respond to treatment in a consistent manner. 2. It should allow for an accurate assessment of a disease state with respect to extent, location and nature of disease. It should not only point to an accurate prognosis but also guide the choice of treatment.

3. Allow clear communication among those treating the disease. As stated by Canis et al, the translation from anatomical lesion to verbal description should be simple, fast, easy to use and clear, thus reducing the influence of the surgeon’s interpretation on a patient’s disease stage. Canis M, Bouquet de Joliniere SJ, Wattiez A, Pouly JL, Mage G, et al. Classification of endometriosis. Clin Obstet Gynecol 1993;7:759.

Critical evaluation of shortcomings of R-ASRM classification and its ability to predict fertility The current classification scheme was primarily designed to address endometriosis in the setting of infertility. Unfortunately it has been shown not be a valuable tool in predicting fertility outcome per stage of disease. Although a general decrease in fecundity is noted as disease severity, and therefore stage of disease progresses, a significant difference can only be shown through combining minimal and mild disease versus moderate and severe disease grouped together

1.r asrm score

2.ENZIAN CLASSIFICATION In view of the lack of description of retroperitoneal structures involving deeply infiltrating endometriosis, the Enzian classification was developed in 2005 . This was not intended to compete with the rASRM score, but rather to supplement it with a description of deeply infiltrating endometriosis

Severity was rated in the same way for all compartments, as follows: The revised version combines morphological structures into compartments in order to simplify the system. Retroperitoneal structures are divided into the following three compartments: • Compartment A, rectovaginal septum and vagina • Compartment B, sacrouterine ligament to pelvic wall • Compartment C, rectum and sigmoid colon Severity was rated in the same way for all compartments, as follows: • Grade 1, invasion <1 cm • Grade 2, invasion 1–3 cm • Grade 3, invasion >3 cm Deep invasion of endometriosis beyond the lesser pelvis and invasion of organs can also be registered separately in the Enzian classification. The prefix “F” stands for “far” or “foreign,” because it refers to retroperitoneal distant locations (FA = adenomyosis, FB = involvement of the bladder, FU = intrinsic involvement of the ureter, FI = bowel disease cranial to the rectosigmoid junction and FO (“other”) = other locations, such as abdominal wall endometriosis).

3.EFI SCORE The EFI is useful only for infertility patients who The EFI can be used to decide what type of treatment patients should undergo, for how long and at what cost before considering the assisted reproductive technologies (ART) following endometriosis surgery. It can be used to provide reassurance for many who have a good prognosis and to avoid wasted time and treatment for those with a poor prognosis. The EFI is useful only for infertility patients who have had surgical staging of their disease. It is not intended to predict any aspect of endometriosis associated pain.

The ‘Least Function Score’ was the sum of the lowest score on each of the right and left sides .It is to be emphasized that the least function score is determined at the completion of the surgical intervention, not before. It therefore represents an estimate of functionality after the surgical intervention.

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