The revised American Society for Reproductive Medicine (rASRM) classification of endometriosis assigns scores based on lesion characteristics. Which finding on laparoscopy would qualify as Stage IV (severe) endometriosis independent of all other findings?

• A Deep infiltrating endometriosis of the uterosacral ligaments with superficial ovarian implants ≤3 cm
• B Bilateral endometriomas >3 cm with partial adhesion of right tube and left ovary
• C Superficial endometriosis >3 cm on the left ovary with filmy left adnexal adhesions
• D Dense bilateral posterior cul-de-sac obliteration alone ✓

Explanation

In the rASRM scoring system, complete obliteration of the posterior cul-de-sac (pouch of Douglas) scores 40 points — which alone places the patient in Stage IV (severe: ≥40 points), regardless of all other findings. Partial cul-de-sac obliteration scores 4 points. Bilateral endometriomas >3 cm and dense adnexal adhesions would each accumulate points but would require multiple findings to reach 40 total. The complete POD obliteration is the one single-finding that is automatically Stage IV.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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