{"paper_id":"148a1432-11e4-4c14-9573-2fbf727b7437","body_text":"Review began\n 05/29/2026 \nReview ended\n 06/14/2026 \nPublished\n 06/19/2026\n© Copyright \n2026\nMishra et al. This is an open access article\ndistributed under the terms of the Creative\nCommons Attribution License CC-BY 4.0.,\nwhich permits unrestricted use, distribution,\nand reproduction in any medium, provided\nthe original author and source are credited.\nDOI:\n 10.7759/cureus.111159\nValidation of Endometriosis Fertility Index for\nthe Prediction of Non-Assisted Reproductive\nTechnology (ART) Pregnancy in Women With\nEndometriosis-Associated Infertility: A\nProspective Cohort Study\nDivya Mishra \n, \nShantanu Shubham \n, \nNeena Malhotra \n1.\n Obstetrics and Gynecology, Graphic Era (Deemed to be University), Dehradun, IND \n2.\n Neonatology, Graphic Era\n(Deemed to be University), Dehradun, IND \n3.\n Obstetrics and Gynecology, All India Institute of Medical Sciences, New\nDelhi, New Delhi, IND\nCorresponding author: \nShantanu Shubham, \ndrshantanushubham@gmail.com\nAbstract\nIntroduction\nEndometriosis is a common cause of infertility and affects reproductive outcomes through multiple\nmechanisms, including pelvic adhesions, altered pelvic anatomy, and inflammatory changes. The\nEndometriosis Fertility Index (EFI) was developed as a prognostic tool to predict spontaneous conception\nafter the surgical treatment of endometriosis. This study aimed to validate the EFI for predicting non-\nassisted reproductive technology (ART) pregnancy outcomes after laparoscopic surgery in women with\nendometriosis-associated infertility and compare its predictive performance with the revised American\nSociety for Reproductive Medicine (r-ASRM) classification.\nMethods\nA prospective cohort study was conducted in the Department of Obstetrics and Gynecology at All India\nInstitute of Medical Sciences (AIIMS), New Delhi, between January 2016 and December 2017 with a six-\nmonth postoperative follow-up. Seventy-two women with endometriosis-associated infertility confirmed\nduring operative laparoscopy were included. EFI scores were calculated postoperatively using historical\nparameters (age, the duration of infertility, and prior pregnancy) and surgical parameters (Least Function\nScore {LFS} and ASRM score). Patients underwent individualized fertility management, including expectant\nmanagement, ovulation induction, and intrauterine insemination (IUI) where indicated. Receiver operating\ncharacteristic (ROC) analysis, Kaplan-Meier survival analysis, and Cox proportional hazards regression were\nperformed to assess predictive accuracy.\nResults\nThe mean EFI score was 6.7 ± 1.6. Women who achieved clinical pregnancy had significantly higher EFI\nscores than those who did not conceive (8.2 ± 1.2 versus 6.0 ± 1.3; p < 0.001). An EFI cut-off of ≥7 predicted\nclinical pregnancy with a sensitivity of 95.8% and specificity of 52.3%, with an area under the curve (AUC) of\n0.90 (95% confidence interval {CI}: 0.82-0.97). The hazard ratio for conception among women with an EFI of\n≥7 was 19.2 (95% CI: 2.6-142.1; p = 0.004). Women with EFI scores of 9-10 demonstrated a 100% pregnancy\nrate within six months. The cumulative probability of non-ART pregnancy at six months was 33.3%. An\nASRM score of <21 also demonstrated predictive capability with an AUC of 0.92.\nConclusion\nEFI demonstrated strong predictive performance for non-ART pregnancy outcomes following laparoscopic\nsurgery in women with endometriosis-associated infertility. The index may serve as a valuable clinical tool\nfor individualized fertility counselling, prognostic assessment, and guiding decisions regarding expectant\nmanagement versus early assisted reproductive intervention.\nCategories:\n Obstetrics/Gynecology\nKeywords:\n endometriosis, endometriosis fertility index, infertility, laparoscopy, pregnancy prediction\nIntroduction\nEndometriosis is defined as the presence of endometrial-like tissue outside the uterine cavity and is\nassociated with a chronic inflammatory response \n[1]\n. It affects approximately 6%-15% of women in the\nreproductive age group and is identified in 25%-50% of infertile women \n[2-5]\n. Infertility with endometriosis\ninvolves multiple factors, such as anatomical distortion, inflammation, altered folliculogenesis, impaired\n1\n2\n3\n \nOpen Access Original Article\nHow to cite this article\nMishra D, Shubham S, Malhotra N (June 19, 2026) Validation of Endometriosis Fertility Index for the Prediction of Non-Assisted Reproductive\nTechnology (ART) Pregnancy in Women With Endometriosis-Associated Infertility: A Prospective Cohort Study. Cureus 18(6): e111159. \nDOI\n10.7759/cureus.111159\n\nendometrial receptivity, and damaged tubal function \n[6,7]\n. Pelvic adhesions resulting from endometriotic\nlesions may disrupt the tubo-ovarian relationship and impair ovum pickup and transport \n[8]\n. Additionally,\ncytokines such as interleukins, tumor necrosis factor-alpha, and vascular endothelial growth factor alter the\nperitoneal environment, impacting oocyte quality and embryogenesis \n[6,7,9]\n.\nThe clinical presentation of endometriosis is heterogeneous, ranging from minimal peritoneal deposits to\nsevere pelvic adhesions and deep infiltrating disease \n[10-13]\n. Various classifications, such as the American\nFertility Society in 1979 and the American Society for Reproductive Medicine (ASRM) in 1985, have been\ndeveloped to standardize diagnosis and aid treatment planning, with the latter being the most widely used\n[13,14]\n. The ASRM scoring system categorizes disease severity based on laparoscopic findings, including\nperitoneal implants, ovarian endometriomas, and adhesions \n[13,15-17]\n.\nThe Endometriosis Fertility Index (EFI) predicts pregnancy without assisted reproductive technology (ART)\nafter the surgical treatment of endometriosis. The EFI incorporates historical factors, including age, the\nduration of infertility, and prior pregnancy history, as well as surgical factors, such as the Least Function\nScore (LFS) and ASRM score. The Least Function Score assesses the postoperative functional status of the\nfallopian tubes, fimbria, and ovaries, providing an estimate of reproductive potential following surgical\ncorrection \n[13]\n. The EFI correlates with pregnancy rates in studies and helps clinicians discuss fertility\nprognosis and need for assisted reproductive therapy \n[17-20]\n. Tomassetti et al. linked the EFI score to the\ntime to non-ART pregnancy in women undergoing laparoscopic endometriosis surgery \n[21]\n. Wang et al.\nfound EFI better than ASRM in predicting in vitro fertilization (IVF) pregnancy outcomes \n[3]\n. Zeng et al.\nshowed higher cumulative pregnancy rates with increasing EFI scores, supporting its predictive power for\nnatural conception \n[20]\n.\nMore recent data support the EFI as a clinically useful prognostic tool in endometriosis-related infertility\nand suggest its use in individualized fertility counselling and treatment planning \n[22,23]\n. Contemporary\nresearch also highlights the potential integration of imaging findings and biomarkers with EFI to improve\nthe predictive accuracy of fertility outcomes \n[24,25]\n.\nA 2020 systematic review in BJOG of 17 studies with 4598 women found that EFI has moderate-to-good\npredictive ability for spontaneous pregnancy after endometriosis surgery. It is the most validated tool for\npredicting pregnancy outcomes without assisted reproduction, with the Least Function Score being the key\nprognostic factor \n[26]\n. Due to heterogeneity among studies, prospective validation in populations other than\nthose in which it was first developed is warranted.\nThe severity of endometriosis was assessed using the revised American Society for Reproductive Medicine\n(r-ASRM) classification system, which remains one of the most widely used surgical staging systems for\nendometriosis \n[15]\n. The Endometriosis Fertility Index (EFI), developed and validated by Adamson and Pasta,\nintegrates historical factors, age, the duration of infertility, pregnancy history, and surgical factors,\nincluding the Least Function Score (LFS), to predict the likelihood of spontaneous conception following\nendometriosis surgery \n[13]\n. The Least Function Score represents the postoperative functional assessment of\nthe fallopian tubes, fimbria, and ovaries and constitutes an important component of the EFI scoring system.\nThe present prospective cohort study was designed to validate the EFI in predicting non-ART pregnancy\noutcomes in women undergoing laparoscopic surgery for endometriosis-associated infertility in India.\nAdditionally, the study aimed to compare the predictive ability of EFI with that of ASRM classification and\nto evaluate its role in estimating time to conception following surgical treatment.\nThis work was previously presented as a poster/abstract at Fertility 2019: Technologies and Controversies in\nReproduction, 3-5 January 2019, International Convention Centre (ICC) Birmingham, United Kingdom.\nMaterials And Methods\nStudy design and setting\nThis prospective cohort study was conducted in the Department of Obstetrics and Gynecology at All India\nInstitute of Medical Sciences (AIIMS), New Delhi, between January 2016 and December 2017, with a follow-\nup period of six months after laparoscopic surgery. All participants were prospectively followed for six\nmonths following laparoscopic surgery, and pregnancy outcomes occurring within this period were included\nin the analysis. The study aimed to assess the predictive performance of EFI on non-ART pregnancy\noutcomes in women with endometriosis-associated infertility. The Institute Ethics Committee for Post\nGraduate Research of All India Institute of Medical Sciences, New Delhi, issued approval IECPG-\n62/27.11.2015, RT-19/30.12.2015.\nStudy population\nWomen with infertility and suspected endometriosis were evaluated. Those undergoing operative\nlaparoscopy with confirmed endometriosis were eligible. Diagnosis was made by laparoscopic visualization,\nwith or without histopathology, the gold standard \n[4]\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n2\n of \n19\n\nInclusion and exclusion criteria\nWomen with surgically corrected endometriosis were included in the study if they were younger than 38\nyears of age, had a body mass index (BMI) between 18 and 28 kg/m², possessed at least one patent fallopian\ntube demonstrated on chromopertubation, had a normal uterine cavity, and had a male partner with normal\nsemen parameters according to the WHO 2010 criteria \n[27]\n. Patients were excluded if they had a history of\nprevious surgery for endometriosis, polycystic ovarian syndrome, genital tuberculosis confirmed by\nhistopathology or culture, bilateral tubal blockage, male factor infertility, intrauterine adhesions, or a\ncompromised uterine cavity.\nSample size calculation\nSample size was estimated based on previously published validation studies by Tomassetti et al. \n[21]\n and\nWang et al. \n[3]\n, which reported cumulative pregnancy rates ranging from 41% to 54%. Assuming an expected\npregnancy rate of approximately 40%-50%, a minimum sample size of 60 participants was calculated to\nachieve 80% power with 5% level of significance for the study duration.\nSurgical evaluation and scoring\nAll participants had laparoscopic surgery for endometriosis diagnosis and treatment. Disease severity was\nstaged during the procedure using the revised ASRM classification based on peritoneal implants, ovarian\nendometriomas, and pelvic adhesions \n[13]\n. After surgical correction, the EFI score was calculated for each\nparticipant using both historical and surgical parameters as described by Adamson and Pasta \n[13]\n. Historical\nfactors included age, infertility duration, and prior pregnancy history. Surgical factors encompassed ASRM\ntotal score, lesion score, and Least Function Score, which reflected postoperative reproductive potential of\nthe fallopian tubes, fimbriae, and ovaries \n[13]\n. EFI scores ranged from 0 to 10, with higher scores indicating a\nbetter prognosis for spontaneous conception.\nFollow-up protocol\nPostoperatively, patients received expectant management or ovulation induction tailored to their profiles,\nincluding clomiphene citrate, gonadotropins, or both, based on age, ovarian reserve, and BMI. Follicular\nmonitoring used transvaginal ultrasonography, and ovulation was triggered with human chorionic\ngonadotropin when the follicle reached ≥18 mm. Intrauterine insemination (IUI) was performed 36 hours\nafter the ovulation trigger when indicated. All women were followed for a period of six months after surgery\nfor the assessment of pregnancy outcomes for six months after surgery.\nOutcome measures\nPrimary outcomes included clinical pregnancy, defined as the ultrasound visualization of an intrauterine\ngestational sac with fetal cardiac activity at ≥6 weeks of gestation; ongoing pregnancy, defined as the\ncontinuation of pregnancy beyond 20 weeks of gestation; and time to conception within six months\nfollowing surgery.\nStatistical analysis\nStatistical analyses evaluated EFI and ASRM scores for pregnancy outcomes. Continuous variables were\nmeans ± SD, categorical and proportions. Receiver operating characteristic (ROC) curves assessed sensitivity,\nspecificity, and predictive values for pregnancy, with the area under the curve (AUC) indicating\nperformance. Kaplan-Meier estimated conception probability over time, tested via log-rank. Cox regression\ncalculated hazard ratios across EFI categories. Odds ratios with 95% confidence intervals (CIs) assessed EFI\ncut-offs and outcomes. P < 0.05 was significant. Statistical analysis was performed using Stata software\nversion 14.0 (StataCorp LLC, College Station, TX).\nResults\nA total of 72 women with endometriosis-associated infertility were recruited from January 2016 at the AIIMS\nGynecology Outpatient Department after undergoing laparoscopic surgery for suspected endometriosis.\nIntraoperative ASRM scores and postoperative EFI scores were calculated using historical and surgical\nparameters. All patients were followed for six months after surgery. The baseline characteristics of the study\npopulation are shown in Table \n1\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n3\n of \n19\n\nVariable (n = 72)\nSummary measures\nAge (years)\n28.8 ± 3.9 (21-38)\n≤35 years\n69 (95.8)\n>35 years\n3 (4.2)\nBMI (kg/m²)\n23.9 ± 2.6 (18-28)\nDuration of infertility (months)\n38.6 ± 29.0 (12-144)\nYears infertile\n≤3 years\n51 (70.8)\n>3 years\n21 (29.2)\nInfertility type\nPrimary\n57 (79.2)\nSecondary\n15 (20.8)\nTABLE\n 1: Demographic characteristics\nData presented as mean ± SD (minimum-maximum) and n (%)\nBMI: body mass index\nMost participants were younger than 35 years, with a mean age of 28.8 ± 3.9 years. The mean body mass\nindex was 23.9 ± 2.6 kg/m². Among the 72 women included in the study, primary infertility was observed in\n57 women (79.2%), and the mean duration of infertility was 38.6 ± 29.0 months. The mean ASRM\nendometriosis lesion score and total ASRM score were 21.7 ± 13.0 and 38.8 ± 29.0, respectively. Following\nsurgical correction, Least Function Scores were categorized as high (7-8) in 19 (26.4%) patients, moderate\n(4-6) in 50 (69.4%) patients, and low (1-3) in three (4.2%) patients. Postoperative EFI scores ranged from 2\nto 10, with a mean score of 6.7 ± 1.6. Patient characteristics related to ASRM and EFI scores are shown in\nTable \n2\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n4\n of \n19\n\nVariable (n = 72)\nSummary measures\nASRM endometriosis score (0-58)\n21.7 ± 13.0 (1-41)\nASRM endometriosis score\n≥16\n57 (79.2)\n<16\n15 (20.8)\nASRM total score (0-178)\n38.8 ± 29.0 (1-124)\nASRM total score\n≥71\n14 (19.4)\n<71\n58 (80.6)\nLeast Function Score (0-8)\n5.7 ± 1.5 (2-8)\nLeast Function Score\nHigh score (7-8)\n19 (26.4)\nModerate score (4-6)\n50 (69.4)\nLow score (1-3)\n3 (4.2)\nEFI score (0-10)\n6.7 ± 1.6 (2-10)\nTABLE\n 2: Patient characteristics related to ASRM and EFI scores\nData presented as mean ± SD (minimum-maximum) and n (%)\nASRM, American Society for Reproductive Medicine; EFI, Endometriosis Fertility Index\nWe compared the postoperative Endometriosis Fertility Index (EFI) scores between women who conceived\nwithin six months after surgery and those who did not. Women who achieved clinical pregnancy had\nsignificantly higher mean EFI scores than those who did not conceive (8.2 ± 1.2 versus 6.0 ± 1.3; p < 0.001),\nindicating a strong positive correlation between higher EFI scores and improved pregnancy outcomes.\nSimilarly, American Society for Reproductive Medicine (ASRM) scores were compared between the two\ngroups. Women who conceived had significantly lower mean ASRM scores compared to those who did not\nachieve pregnancy (12.8 ± 14.4 versus 51.8 ± 25.6; p < 0.001). These findings suggest that lower ASRM scores\nwere associated with a greater likelihood of conception within six months following surgery. The correlation\nof EFI and ASRM scores with clinical pregnancy outcomes is shown in Table \n3\n.\nVariable\nTotal score\nWith clinical pregnancy\nWithout clinical pregnancy\nP value\nEFI score\n6.7 ± 1.6\n8.2 ± 1.2\n6.0 ± 1.3\n<0.001\nASRM score\n38.8 ± 29.0\n12.8 ± 14.4\n51.8 ± 25.6\n<0.001\nTABLE\n 3: Correlation of EFI and ASRM scores with clinical pregnancy\nData presented as mean ± SD and p < 0.05 is statistically significant\nASRM, American Society for Reproductive Medicine; EFI, Endometriosis Fertility Index\nReceiver operating characteristic (ROC) analysis was performed using an Endometriosis Fertility Index (EFI)\nscore cut-off of ≥7 and an American Society for Reproductive Medicine (ASRM) score cut-off of <21 for the\nprediction of clinical pregnancy. For an EFI of ≥7, the sensitivity and specificity for predicting clinical\npregnancy were 95.8% (95% CI: 79.8-99.3) and 52.3% (95% CI: 37.9-66.3), respectively, with an area under\nthe curve (AUC) of 0.90 (95% CI: 0.82-0.97).\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n5\n of \n19\n\nFor an ASRM score of <21, the sensitivity and specificity were 83.3% (95% CI: 64.2-93.3) and 79.2% (95% CI:\n65.7-88.3), respectively, with an AUC of 0.92 (95% CI: 0.86-0.98). The ROC analysis for the prediction of\nclinical pregnancy using EFI and ASRM score cut-offs is shown in Table \n4\n.\nCut-off\nEFI score (≥7)\nASRM score (<21)\nTP\n23\n20\nFP\n21\n10\nTN\n27\n38\nFN\n1\n4\nSensitivity (95% CI)\n95.8% (79.8-99.3)\n83.3% (64.2-93.3)\nSpecificity (95% CI)\n52.3% (37.9-66.3)\n79.2% (65.7-88.3)\nPPV (95% CI)\n52.3% (37.9-66.3)\n66.7% (48.8-80.8)\nNPV (95% CI)\n95.8% (79.8-99.3)\n90.5% (77.9-96.2)\nAUC (95% CI)\n0.90 (0.82-0.97)\n0.92 (0.86-0.98)\nTABLE\n 4: Cut-offs of EFI and ASRM scores against clinical pregnancy using ROC analysis\nASRM, American Society for Reproductive Medicine; AUC, area under the curve; CI, confidence interval; EFI, Endometriosis Fertility Index; FN, false\nnegative; FP, false positive; NPV, negative predictive value; PPV, positive predictive value; TN, true negative; TP, true positive; ROC, receiver operating\ncharacteristic\nAs shown in Table \n4\n, the EFI score cut-off of ≥7 demonstrated higher sensitivity and negative predictive\nvalue compared to the ASRM score cut-off of <21. However, the area under the curve (AUC) values from\nreceiver operating characteristic (ROC) analysis were comparable for both scores, suggesting similar\npredictive ability for clinical pregnancy in the study population. Both EFI and ASRM score cut-offs showed\nstatistically significant associations with clinical pregnancy outcomes (p = 0.001 and p < 0.001, respectively).\nThe ROC curves for EFI and ASRM scores in relation to clinical pregnancy are shown in Figure \n1\n and Figure\n2\n, respectively.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n6\n of \n19\n\nFIGURE\n 1: Correlation between EFI score and clinical pregnancy using\nROC analysis\nThe small blue circles represent the individual sensitivity and specificity coordinate points obtained at different cut-\noff values of the respective scoring systems on the ROC curve. The solid blue line connecting these points\nrepresents the ROC curve, illustrating the diagnostic performance of the score across varying thresholds. The\ndiagonal straight line represents the line of no discrimination (reference line), indicating the performance expected\nby chance alone (area under the curve = 0.5)\nEFI, Endometriosis Fertility Index; ROC, receiver operating characteristic\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n7\n of \n19\n\nFIGURE\n 2: Correlation between ASRM score and clinical pregnancy\nusing ROC analysis\nThe small blue circles represent the individual sensitivity and specificity coordinate points obtained at different cut-\noff values of the respective scoring systems on the ROC curve. The solid blue line connecting these points\nrepresents the ROC curve, illustrating the diagnostic performance of the score across varying thresholds. The\ndiagonal straight line represents the line of no discrimination (reference line), indicating the performance expected\nby chance alone (area under the curve = 0.5)\nASRM, American Society for Reproductive Medicine; ROC, receiver operating characteristic\nThe same EFI and ASRM score cut-offs were used for predicting ongoing pregnancy outcomes. For an EFI\nscore cut-off of ≥7, the sensitivity and specificity were 94.7% (95% CI: 75.4-99.1) and 50.9% (95% CI: 37.9-\n63.9), respectively, with an AUC of 0.86 (95% CI: 0.76-0.96). Similarly, using an ASRM score cut-off of <21,\nthe sensitivity and specificity for predicting ongoing pregnancy were 84.2% (95% CI: 62.3-94.5) and 73.6%\n(95% CI: 60.4-83.6), respectively, with an AUC of 0.87 (95% CI: 0.79-0.96). The predictive performance of\nEFI and ASRM score cut-offs for ongoing pregnancy is shown in Table \n5\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n8\n of \n19\n\nCut-off\nEFI score (≥7)\nASRM score (<21)\nTP\n18\n16\nFP\n26\n14\nTN\n27\n39\nFN\n1\n3\nSensitivity (95% CI)\n94.7% (75.4-99.1)\n84.2% (62.3-94.5)\nSpecificity (95% CI)\n50.9% (37.9-63.9)\n73.6% (60.4-83.6)\nPPV (95% CI)\n40.9% (27.7-55.6)\n53.3% (36.1-69.8)\nNPV (95% CI)\n96.4% (82.3-99.4)\n92.9% (81.0-97.5)\nAUC (95% CI)\n0.86 (0.76-0.96)\n0.87 (0.79-0.96)\nTABLE\n 5: Cut-offs of EFI and ASRM scores against ongoing pregnancy using ROC analysis\nASRM, American Society for Reproductive Medicine; AUC, area under the curve; CI, confidence interval; EFI, Endometriosis Fertility Index; FN, false\nnegative; FP, false positive; NPV, negative predictive value; PPV, positive predictive value; TN, true negative; TP, true positive; ROC, receiver operating\ncharacteristic\nAs shown in Table \n5\n, the sensitivity of the EFI score for predicting ongoing pregnancy was higher than that\nof the ASRM score. However, the AUC values obtained from ROC analysis for EFI and ASRM scores were\ncomparable (0.86 and 0.87, respectively), suggesting similar predictive performance for ongoing pregnancy\nin the study population. The selected cut-offs for both EFI and ASRM scores in predicting clinical and\nongoing pregnancy outcomes were statistically significant. For ongoing pregnancy, the p values for EFI and\nASRM score cut-offs were 0.006 and <0.001, respectively. The ROC curves of EFI and ASRM scores plotted\nagainst ongoing pregnancy rates are shown in Figure \n3\n and Figure \n4\n, respectively.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n9\n of \n19\n\nFIGURE\n 3: Correlation between EFI score and ongoing pregnancy using\nROC analysis\nThe small blue circles represent the individual sensitivity and specificity coordinate points obtained at different cut-\noff values of the respective scoring systems on the ROC curve. The solid blue line connecting these points\nrepresents the ROC curve, illustrating the diagnostic performance of the score across varying thresholds. The\ndiagonal straight line represents the line of no discrimination (reference line), indicating the performance expected\nby chance alone (area under the curve = 0.5)\nEFI, Endometriosis Fertility Index; ROC, receiver operating characteristic\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n10\n of \n19\n\nFIGURE\n 4: Correlation between ASRM score and ongoing pregnancy\nusing ROC analysis\nThe small blue circles represent the individual sensitivity and specificity coordinate points obtained at different cut-\noff values of the respective scoring systems on the ROC curve. The solid blue line connecting these points\nrepresents the ROC curve, illustrating the diagnostic performance of the score across varying thresholds. The\ndiagonal straight line represents the line of no discrimination (reference line), indicating the performance expected\nby chance alone (area under the curve = 0.5)\nASRM, American Society for Reproductive Medicine; ROC, receiver operating characteristic\nThe probability of conception following surgery was evaluated using Kaplan-Meier analysis and plotted\nagainst time to conception, as shown in Figure \n5\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n11\n of \n19\n\nFIGURE\n 5: Probability of clinical pregnancy within six months after\nsurgery for endometriosis\nThe cumulative probability of conception increased progressively from approximately 0.05 to 0.30 between\nthe second and fifth postoperative months, after which the curve demonstrated a plateau during the sixth\nmonth. Since the follow-up period in the present study was limited to six months after surgery, the\nprobability of conception beyond this duration could not be assessed.\nKaplan-Meier analysis stratified according to EFI score categories (<7 and ≥7) demonstrated a significantly\nhigher probability of conception and shorter time to pregnancy in women with EFI scores of ≥7 compared to\nthose with EFI scores of <7, as shown in Figure \n6\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n12\n of \n19\n\nFIGURE\n 6: Correlation between EFI and the probability of non-ART\npregnancy using EFI cut-off\nEFI, Endometriosis Fertility Index; non-ART, non-assisted reproductive technology\nThese findings suggest that higher EFI scores are associated with improved non-ART pregnancy outcomes\nfollowing corrective surgery for endometriosis and further support the utility of EFI as a valuable prognostic\ntool in women with endometriosis-associated infertility.\nKaplan-Meier analysis across different EFI categories (0-6, 7, 8, and 9-10) demonstrated progressively\nincreasing probabilities of clinical pregnancy with increasing EFI scores. Women with EFI scores of 9-10\nshowed the highest probability of conception, with pregnancy rates increasing between the second and sixth\npostoperative months and reaching maximum probability between the second and third months. In women\nwith an EFI score of 8, the probability of clinical pregnancy increased from 0.1 at the end of the third month\nto 0.7 at the end of the sixth month, with the greatest increase observed during the fourth postoperative\nmonth. For patients with an EFI score of 7, the probability increased from 0.1 during the third and fourth\nmonths to 0.25 by the sixth month. Among patients with EFI scores between 0 and 6, only one achieved a\nclinical pregnancy during the sixth postoperative month. The comparison of Kaplan-Meier curves using the\nlog-rank test demonstrated a statistically significant difference among EFI categories (p < 0.001), indicating\nthat higher EFI scores were associated with better clinical pregnancy outcomes. The Kaplan-Meier curves for\nthe different EFI categories are shown in Figure \n7\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n13\n of \n19\n\nFIGURE\n 7: Probability of clinical pregnancy classified by EFI scores\nduring a six-month follow-up of 72 infertile patients after surgery for\nendometriosis (p < 0.001)\nEFI: Endometriosis Fertility Index\nThe probability of clinical pregnancy at six months following surgery for endometriosis, derived from\nKaplan-Meier analysis across different EFI categories, is presented in tabulated form in Table \n6\n.\nEFI score\nProbability of clinical pregnancy\n0-6\n0.04 (95% CI: 0.23-0.01)\n7\n0.25 (95% CI: 0.47-0.12)\n8\n0.67 (95% CI: 0.92-0.38)\n9-10\n1.00\nTABLE\n 6: Probability of clinical pregnancy at six months in different EFI groups\nCI, confidence interval; EFI, Endometriosis Fertility Index\nAfter establishing the optimal cut-offs for EFI and ASRM scores for predicting pregnancy outcomes in the\nstudy population, odds ratios with 95% confidence intervals were calculated for clinical pregnancy. Women\nwith an EFI score of ≥7 had an odds ratio of 29.6 for achieving a clinical pregnancy, whereas women with an\nASRM score of <21 had an odds ratio of 19.0. Both associations were statistically significant, indicating a\nstrong relationship between these score cut-offs and the likelihood of clinical pregnancy. The odds ratios for\nclinical pregnancy according to EFI and ASRM score cut-offs are presented in Table \n7\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n14\n of \n19\n\nVariable\nClinical pregnancy (n = 24)\nNo clinical pregnancy (n = 48)\nOdds ratio (95% CI)\nP value\nEFI score\n \n \n \n \n≥7\n23 (95.8%)\n21 (43.7%)\n29.6 (3.7-237.1)\n0.001\n<7\n1 (4.2%)\n27 (56.2%)\nReference\n-\nASRM score\n \n \n \n \n<21\n20 (83.3%)\n10 (20.8%)\n19.0 (5.3-68.3)\n<0.001\n≥21\n4 (16.7%)\n38 (79.2%)\nReference\n-\nTABLE\n 7: Odds ratio of clinical pregnancy according to cut-offs for EFI and ASRM scores\nData presented as n (%). P < 0.05 is considered statistically significant\nEFI, Endometriosis Fertility Index; ASRM, American Society for Reproductive Medicine; CI, confidence interval\nSimilarly, odds ratios for ongoing pregnancy were calculated using the established EFI and ASRM score cut-\noffs. Women with an EFI score of ≥7 had an odds ratio of 18.7 for achieving ongoing pregnancy, which was\nstatistically significant (p = 0.006). Likewise, women with an ASRM score of <21 had an odds ratio of 14.8,\nwhich also demonstrated statistical significance (p < 0.001). The odds ratios for ongoing pregnancy\naccording to EFI and ASRM score cut-offs are presented in Table \n8\n.\nVariable\nOngoing pregnancy (n = 19)\nNo ongoing pregnancy (n = 53)\nOdds ratio (95% CI)\nP value\nEFI score\n \n \n \n \n≥7\n18 (94.7%)\n26 (49.1%)\n18.7 (2.3-150.3)\n0.006\n<7\n1 (5.3%)\n27 (50.9%)\nReference\n-\nASRM score\n \n \n \n \n<21\n16 (84.2%)\n14 (26.4%)\n14.8 (3.7-58.8)\n<0.001\n≥21\n3 (15.8%)\n39 (73.6%)\nReference\n-\nTABLE\n 8: Odds ratio of ongoing pregnancy according to cut-offs for EFI and ASRM scores\nData presented as n (%). P < 0.05 is considered statistically significant\nEFI, Endometriosis Fertility Index; ASRM, American Society for Reproductive Medicine; CI, confidence interval\nCox proportional hazards regression analysis was performed to evaluate the association between different\nEFI score groups and time to conception following surgery for endometriosis. Women with an EFI score of ≥7\nhad a significantly higher likelihood of conceiving within six months after surgery compared to those with\nEFI scores of <7, with a hazard ratio of 19.2 (95% CI: 2.6-142.1; p = 0.004). The hazard ratio progressively\nincreased with increasing EFI scores, indicating that higher EFI scores were associated with a shorter time to\nconception. Statistically significant associations were observed for EFI scores above 7. The hazard ratios for\ndifferent EFI score categories are presented in Table \n9\n.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n15\n of \n19\n\nEFI score\nHazard ratio (95% CI)\nP value\nBinary grouping\n \n \n<7\nReference\n-\n≥7\n19.2 (2.6-142.1)\n0.004\nCategorical grouping\n \n \n0-6\nReference\n-\n7\n8.1 (0.97-67.4)\n0.053\n8\n29.4 (3.4-251)\n0.002\n9-10\n50.5 (6.1-418.3)\n<0.001\nTABLE\n 9: Proportional hazard analysis of EFI scores against time taken for pregnancy after\nsurgery\nP < 0.05 is considered statistically significant\nEFI, Endometriosis Fertility Index; CI, confidence interval\nAmong the 72 women included in the study, the majority had Endometriosis Fertility Index (EFI) scores\nranging between 5 and 8, with 24 women (33.3%) having an EFI score of 7. Patients were categorized into\nfive groups based on their EFI scores. Among women with EFI scores of 9-10, all 11 women (100%) achieved\nclinical pregnancy within six months following surgery; however, three (27.3%) experienced spontaneous\nabortions before 20 weeks, resulting in eight ongoing pregnancies (72.7%). Among the 33 women with EFI\nscores of 7-8, 12 women (36.4%) achieved clinical pregnancy, of whom two (16.7%) experienced\nspontaneous abortions, resulting in 10 ongoing pregnancies (30.3%). In the EFI score group of 5-6, only one\npatient (5.9%) achieved pregnancy within six months, whereas no pregnancies were observed among\npatients with EFI scores of ≤4. No ectopic pregnancies occurred in the study population. The cumulative\nclinical and ongoing pregnancy rates across different EFI groups within six months after surgery are\npresented in Table \n10\n.\nEFI\nscore\nNumber of\npatients\nNumber of patients with clinical pregnancy within six\nmonths after surgery\nNumber of patients with\nongoing pregnancy\nNumber of\nmiscarriages\n0-2\n1\n0\n0\n0\n3-4\n5\n0\n0\n0\n5-6\n22\n1 (4.5)\n1 (4.5)\n0\n7-8\n33\n12 (36.4)\n10 (30.3)\n2 (16.7)\n9-10\n11\n11 (100)\n8 (72.7)\n3 (27.3)\nTABLE\n 10: EFI scores and cumulative pregnancy rate\nEFI: Endometriosis Fertility Index\nDiscussion\nThis cohort study supports EFI as a strong predictor of pregnancy outcomes without assisted reproductive\ntechnologies after laparoscopic surgery in infertile women with endometriosis. Women with higher EFI\nscores had a higher chance of conceiving within six months, highlighting its prognostic value. The predictive\naccuracy of EFI in the present study was supported by high sensitivity (95.8%), area under the curve (AUC) of\n0.90, and a strong hazard ratio of 19.2 for conception among women with an EFI of ≥7. Therefore, this index\nis a promising tool for assessing the probability of spontaneous conception after the surgical treatment of\nendometriosis.\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n16\n of \n19\n\nThis study shows that EFI offers valuable prognostic information for counselling patients on reproductive\npotential after surgery. Higher EFI scores link to higher pregnancy chances and faster conception,\nhighlighting that reproductive organ health impacts outcomes in women with endometriosis.\nThe ASRM classification system is currently the gold standard for staging endometriosis, but studies have\nshown that the staging of endometriosis according to ASRM has poor prognostic value for fertility outcomes\n[13,17,28,29]\n. Because it is an anatomical classification, it does not predict postoperative reproductive\nfunction or include key fertility parameters such as infertility duration or prior pregnancy history \n[15,16]\n.\nHence, ASRM alone cannot provide adequate prognostic information for fertility counselling and decision-\nmaking.\nEFI incorporates reproductive parameters, filling a gap in endometriosis classification that emphasizes\nanatomy but neglects reproductive potential. It links postoperative adnexal function to patient\ncharacteristics, helping estimate spontaneous pregnancy and guide treatment.\nThe present data are consistent with the initial study by Adamson and Pasta showing increasing cumulative\npregnancy rates with increasing EFI scores \n[13]\n. In that original report, the EFI became the first validated\nclassification system for endometriosis, enabling the prediction of fertility after surgery.\nWang et al. evaluated the predictive ability of EFI in women undergoing IVF treatment following the surgical\nmanagement of endometriosis and demonstrated that EFI showed better predictive performance than the\nASRM classification \n[3]\n. This suggests that EFI might be applicable for predicting reproductive outcomes\nacross various cycles. Li et al. showed that EFI may help clinicians decide the timing of assisted reproductive\ntechniques post surgery \n[17]\n. Women with low EFI should pursue early ART, while those with higher EFI\nmight try spontaneous pregnancy first, considering ART.\nGaravaglia et al. demonstrated the predictive value of EFI in both spontaneous conception and assisted\nreproductive outcomes, further supporting its clinical utility \n[19]\n. Maheux-Lacroix et al. demonstrated a\nstrong correlation between the EFI score and live birth rates following surgical treatment for moderate and\nsevere endometriosis \n[30]\n. Their findings highlight the importance of EFI as a clinically relevant prognostic\ntool that can predict meaningful reproductive outcomes beyond initial conception.\nA systematic review and meta-analysis published in BJOG in 2020 evaluated 17 studies including 4598\nwomen and confirmed that EFI demonstrates moderate-to-good predictive performance for spontaneous\npregnancy following endometriosis surgery \n[26]\n. The review concluded that EFI remains the most validated\nclinical tool for predicting non-assisted reproductive technique pregnancy outcomes and emphasized the\nimportance of the Least Function Score as a major determinant of reproductive prognosis.\nThe Least Function Score represents postoperative functional status of the fallopian tubes, fimbria, and\novaries and is considered one of the most important components of EFI \n[13]\n. Previous studies have\nconsistently demonstrated that the Least Function Score contributes significantly to the predictive ability of\nEFI \n[17,21]\n. The functional integrity of adnexal structures influences the chance of spontaneous conception\nand may explain why anatomical staging alone has limited predictive ability.\nEFI offers an objective way for clinicians to estimate spontaneous conception chances after laparoscopic\nendometriosis surgery. Patients with higher EFI scores might benefit from expectant management or\novulation induction before assisted reproductive techniques. Conversely, patients with low EFI scores may\nbe counselled for early referral to assisted reproductive technologies, thereby reducing delay in achieving\npregnancy.\nEFI may therefore assist clinicians in individualized fertility counselling and improve shared decision-\nmaking regarding treatment strategies. The use of EFI in routine clinical practice may help optimize fertility\noutcomes and reduce unnecessary delay in the initiation of assisted reproductive techniques.\nLimitations\nThis study has several limitations. First, it was conducted at a single center with a relatively small sample\nsize and only 24 clinical pregnancy events, which may have limited the precision and stability of effect\nestimates, including ROC-derived performance measures and hazard ratios. Second, the follow-up period\nwas limited to six months, whereas most EFI validation studies have reported cumulative pregnancy\noutcomes over 12-36 months; therefore, pregnancies occurring beyond six months and live birth outcomes\nwere not captured. Third, postoperative fertility management was individualized and included ovulation\ninduction and/or IUI in selected patients. Details of postoperative fertility management, including expectant\nmanagement, ovulation induction, and intrauterine insemination, were not systematically recorded.\nTherefore, the potential influence of these interventions on pregnancy outcomes and time to conception\ncould not be assessed. Consequently, the study reflects pregnancy outcomes following surgery within a non-\nIVF treatment pathway rather than purely spontaneous conception, introducing the possibility of treatment-\neffect bias and residual confounding. Fourth, multivariable Cox regression adjusting for potential\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n17\n of \n19\n\nconfounders was not performed because of the modest sample size and limited number of events. Fifth, the\nEFI cut-off of ≥7 was derived from ROC analysis within the study cohort and was not prospectively pre-\nspecified, raising the possibility of optimism bias. Finally, the observed 100% clinical pregnancy rate in the\nEFI 9-10 subgroup should be interpreted cautiously because it was based on only 11 participants. Larger\nmulticentric studies with longer follow-up, live birth assessment, standardized postoperative management,\nand external validation are needed to further establish the predictive performance and generalizability of\nEFI.\nConclusions\nThe present study successfully validated the Endometriosis Fertility Index (EFI) as a predictor of non-ART\npregnancy outcomes in women with endometriosis-associated infertility following laparoscopic surgery.\nHigher clinical and ongoing pregnancy rates were observed among women with higher EFI scores.\nFurthermore, life table analysis demonstrated a significant relationship between EFI score and time to\nconception, indicating that increasing EFI scores were associated with improved fertility outcomes following\nthe surgical management of endometriosis.\nBoth EFI and r-ASRM scores demonstrated good predictive performance for clinical and ongoing pregnancy\noutcomes. While EFI showed higher sensitivity for identifying women likely to conceive, r-ASRM\ndemonstrated higher specificity, indicating a trade-off between the two scoring systems. The overall\ndiscriminative ability of EFI and r-ASRM was comparable, as reflected by similar areas under the ROC curve.\nHowever, EFI offers additional clinical value by incorporating both historical and postoperative functional\nfactors and by providing prognostic information regarding the likelihood and timing of conception following\nsurgery. These findings support the use of EFI as a valuable fertility prognostic tool that may assist in\nindividualized patient counselling, fertility prognostication, and decision-making regarding postsurgical\nfertility management strategies in women with endometriosis-associated infertility.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nAcquisition, analysis, or interpretation of data:\n  \nShantanu Shubham, Divya Mishra, Neena Malhotra\nDrafting of the manuscript:\n  \nShantanu Shubham, Divya Mishra\nConcept and design:\n  \nDivya Mishra, Neena Malhotra\nCritical review of the manuscript for important intellectual content:\n  \nNeena Malhotra\nSupervision:\n  \nNeena Malhotra\nDisclosures\nHuman subjects:\n Informed consent for treatment and open access publication was obtained or waived by all\nparticipants in this study. The Institute Ethics Committee for Post Graduate Research of All India Institute of\nMedical Sciences, New Delhi, issued approval IECPG-62/27.11.2015, RT-19/30.12.2015, dated 06.01.2016.\nAnimal subjects:\n All authors have confirmed that this study did not involve animal subjects or tissue.\nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all authors declare the\nfollowing: \nPayment/services info:\n All authors have declared that no financial support was received from\nany organization for the submitted work. \nFinancial relationships:\n All authors have declared that they have\nno financial relationships at present or within the previous three years with any organizations that might\nhave an interest in the submitted work. \nOther relationships:\n All authors have declared that there are no\nother relationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nKennedy S, Bergqvist A, Chapron C, et al.: \nESHRE guideline for the diagnosis and treatment of\nendometriosis\n. 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Hum\nReprod. 2017, 32:2243-9. \n10.1093/humrep/dex291\n \n2026 Mishra et al. Cureus 18(6): e111159. DOI 10.7759/cureus.111159\n19\n of \n19","source_license":"CC0","license_restricted":false}