AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score

J Minim Invasive Gynecol. 2021 Nov;28(11):1941-1950.e1. doi: 10.1016/j.jmig.2021.09.709. Epub 2021 Sep 25.


Study objective: To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.

Design: Multicenter study of patients treated at 3 recognized endometriosis centers.

Setting: Three specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.

Patients: Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.

Interventions: Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.

Measurements and main results: A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.

Conclusion: The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.

Keywords: Endometriosis; Infertility; Laparoscopy; Pelvic pain; Staging.

Publication types

  • Multicenter Study

MeSH terms

  • Brazil
  • Dysmenorrhea / etiology
  • Dyspareunia* / etiology
  • Endometriosis* / complications
  • Endometriosis* / diagnosis
  • Endometriosis* / surgery
  • Female
  • Humans
  • Laparoscopy*
  • Pelvic Pain / etiology
  • Reproducibility of Results
  • United States