The matched pairs sign test using bivariate ranked set sampling (BVRSS) is introduced and investigated. We show that this test is asymptotically more efficient than its counterpart sign test based on a bivariate simple random sample (BVSRS). The asymptotic null distribution and the efficiency of the test are derived. The Pitman asymptotic relative efficiency is used to compare the asymptotic performance of the matched pairs sign test using BVRSS versus using BVSRS. For small sample sizes, the bootstrap method is used to estimate P-values. Numerical comparisons and real data are used to gain insight about the efficiency of the BVRSS sign test compared to the BVSRS sign test. Our numerical and theoretical results indicate that using BVRSS for the matched pairs sign test is substantially more efficient than using BVSRS
