{"paper_id":"99715251-0a2c-4c95-b8ca-15e2db69545e","body_text":"Yangtze Medicine, 2026, 10(1), 16-34 \nhttps://www.scirp.org/journal/ym \nISSN Online: 2475-7349 \nISSN Print: 2475-7330 \n \nDOI: 10.4236/ym.2026.101003  Mar. 10 , 2026 16 Yangtze Medicine \n \n \n \n \nImpact of Endometriosis on Fertility and \nQuality of Life among Women of Childbearing \nAge: A Comparative Hospital-Based  \nCross-Sectional Study in China and Rwanda \nFabiola Irafasha1,2 , Hua Wei1,2, Stephano Lydia Donasiao2, Qingsong Zeng1 , Cunjian Yi1,2* \n1Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Yangtze University, The First People’s Hospital of \nJingzhou, Jingzhou, China \n2School of Medicine, Yangtze University, Jingzhou, China \n \n \n \nAbstract \nBackground:  Endometriosis is associated with chronic pelvic pain, dysmen-\norrhea, and infertility, leading to substantial healthcare costs and diminished \nquality of life (QoL). While early diagnosis may improve outcomes, little is \nknown about women’s experiences across resource-diverse settings. This study \ncompared the impact of endometriosis on fertility and QoL among women of \nreproductive age in China and Rwanda. Methods:  A cross-sectional study was \nconducted from January to November 2025 in four hospitals across China and \nRwanda. Women aged 18 - 45 years with surgically confirmed endometriosis \nwere enrolled, excluding those with comorbidities affecting infertility or QoL. \nData were collected using the validated 63-item Endometriosis Impact Ques-\ntionnaire (EIQ). Multiple linear regression identified predictors of EIQ scores, \nand logistic regression assessed factors associated with self-reported infertility, \nusing a 5% significance level. Results:  Among 153 participants, 66.7% were \nfrom China; median age was 31 years (IQR: 25 - 39), and 47.7% had tertiary \neducation. Median monthly income was higher in China than Rwanda ($674.8 \nvs $103.5; p < 0.001), while health insurance coverage was higher in Rwanda \n(84.3% vs 66.7%; p = 0.022). Of 113 sexually active women, 62.8% reported \ninfertility, more frequently in China (74.3% vs 41.0%; p < 0.001). The overall \nmedian EIQ score was 43.3 (IQR 14.2 - 58.5), with no significant difference \nbetween countries across recall periods. However, Rwandan women reported \nlower impact in the fertility, sexual, and lifestyle domains (p < 0.05), while no \ndifferences were observed in physical, psychological, social, educational, or \nemployment domains. After adjusting for confounders, country of residence \nHow to cite this paper: Irafasha, F., Wei, \nH., Donasiao, S.L., Zeng, Q.S. and Yi, C.J. \n(2026) Impact of Endometriosis on Fertility \nand Quality of Life among Women of \nChildbearing Age: A Comparative Hospi-\ntal-Based Cross-Sectional Study in China \nand Rwanda. Yangtze Medicine, 10, 16-34. \nhttps://doi.org/10.4236/ym.2026.101003 \n \nReceived:  January 11, 2026 \nAccepted: March 7, 2026 \nPublished: March 10, 2026 \n \nCopyright © 2026 by author(s) and  \nScientific Research Publishing Inc. \nThis work is licensed under the Creative \nCommons Attribution International  \nLicense (CC BY 4.0). \nhttp://creativecommons.org/licenses/by/4.0/   \n  \nOpen Access\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 17 Yangtze Medicine \n \ndid not predict EIQ scores (β = 4.5; p = 0.484), whereas secondary (β = –13.6; \np = 0.049) and tertiary education (β = –17.0; p = 0.022) were associated with \nlower impact scores. Higher income was associated with reported infertility \n(aOR = 1.002; p = 0.034). Surgical management was common in both coun-\ntries, but IVF and IUI were accessed only in China, where satisfaction with \ncare was higher (median 4 vs 2). Conclusion:  Endometriosis substantially im-\npairs the QoL of women in both China and Rwanda, with no differences in \noverall impact between the two settings. However, domain-specific variations \nwere observed, and higher education was associated with better QoL out-\ncomes. Infertility was common, particularly among women with higher in-\ncomes, and advanced fertility treatments were accessible only in China, where \nsatisfaction with care was also higher. These findings highlight the need to \nstrengthen diagnostic capacity, expand fertility services, and improve compre-\nhensive endometriosis care, especially in resource-limited settings. \n \nKeywords \nEndometriosis, Fertility, Quality of Life, Reproductive Health, Endometriosis \nImpact Questionnaire \n \n1. Background \nEndometriosis is a chronic gynaecological condition characterised by the presence \nof endometrial tissue outside the uterus [1]. It is one of the most common gynae-\ncological conditions affecting over 10% of women of reproductive age globally [2]. \nBecause of its insidious onset, a substantial number of cases remain undiagnosed, \nand its epidemiology is said to be underreported [3]. Nonetheless, literature indi-\ncates that over 30% - 50% of the affected women experience infertility [4], while \nmany others suffer chronic pelvic pain, dysmenorrhea, and dyspareunia, which \naffect their quality of life [5] [6]. \nDiagnostic delays remain a defining challenge, with studies reporting an aver-\nage lag of 7 - 10 years between symptom onset and confirmed diagnosis [7] [8]. \nThese delays often arise from nonspecific symptoms, normalisation of menstrual \npain, and limited healthcare provider awareness [9]. Such barriers are particularly \nprevalent in low-resource settings like Rwanda, where specialised gynaecological \nservices and advanced diagnostic technologies remain scarce. More industrialised \ncountries, such as China, have better healthcare infrastructure, but disparities in \ntimely diagnosis and treatment outcomes persist. Even where care is accessible, \ntreatment options like surgery and hormonal therapy are often associated wit h \nvarying success and may be accompanied by recurrence, side effects, or complica-\ntions such as infertility and chronic pain [10]-[12]. \nThese challenges present a substantial toll on the overall physical, social, men-\ntal, and psychological well-being of women, thus negatively affecting the overall \nquality of life (QoL). Studies have indicated that patients with endometriosis re-\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 18 Yangtze Medicine \n \nport higher rates of anxiety, depression, and social isolation than their peers [13], \n[14]. The burden also has economic implications due to lost productivity and costs \nassociated with healthcare [15]. However, evidence shows that early, holistic man-\nagement can substantially improve women’s well-being and productivity [16] \n[17]. \nAlthough substantial research has been conducted on endometriosis globally, \nthere remains a paucity of comparative studies examining the condition across \ndiverse socio-cultural and healthcare settings. Rwanda and China provide unique \ncontexts for such a study, given their contrasting healthcare systems, population \ndemographics, and cultural attitudes toward reproductive health. This study was \ntherefore conducted to address the gap by comparing the impact of endometriosis \non fertility and quality of life in women of childbearing age in Rwanda and China. \nThe study also explored fertility challenges, treatment options, and women’s per-\nceptions of treatment effectiveness across these contrasting settings. Understand-\ning these disparities is crucial for tailored interventions and policy recommenda-\ntions to improve care for women globally. In addition to existing literature, this \nstudy sheds more light on how healthcare systems, cultural attitudes, and socio-\neconomic factors shape the experiences of women with endometriosis. \n2. Methods \n2.1. Study Design and Settings \nThis was a quantitative cross-sectional study conducted across two economically \ndiverse settings in China and Rwanda from January to November 2025. In each \ncountry, two facilities were purposively selected based on the diagnostic capacity \nand availability of a gynaecology outpatient clinic where participants could be \nsampled. In China, these facilities included The First People’s Hospital of Jingzhou \n(FPHJ) and Jingzhou Central Hospital (JCH), while in Rwanda, University Teach-\ning Hospital of Kigali (CHUK) and King Faisal Hospital, Rwanda (KFHR) were \nselected. \nChina is a fast-growing upper-middle-income country located in East Asia, with \na total land area of approximately 9.6 million square kilometres and a population \nexceeding 1.4 billion people. The country has a tiered healthcare system compris-\ning primary, secondary, and tertiary levels, with tertiary hospitals serving a s re-\ngional or national referral centres offering specialised and technologically advanced \ncare. The present study was conducted in Jingzhou City, located in Hubei Prov-\nince, Central China. Jingzhou has a population of over 5.5 million people and is a \nrapidly developing urban area with expanding industrial and educational infra-\nstructure. Both FPHJ and JCH are tertiary-level referral and teaching hospitals \naffiliated with Yangtze University. These facilities provide a wide range of special-\nist services, including advanced gynaecological and reproductive health care, and \nare equipped with modern diagnostic technologies such as laparoscopic surgery, \nmagnetic resonance imaging (MRI), and assisted reproductive technologies (ART). \nChina’s health system operates through a mixed model, combining government \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 19 Yangtze Medicine \n \nsubsidies, social health insurance, and out-of-pocket payments.  \nIn contrast, Rwanda is a landlocked low-income country located in East Africa. \nIt is a small country covering 10,169 square miles on the ground with an estimated \npopulation size of 14 million people. The public health sector in Rwanda is organ-\nised into three levels (peripheral, intermediate and central) with each level having \ndefined technical and administrative platforms. The peripheral level is at the dis-\ntrict level, consisting of the district health offices with a district hospital, and pri-\nmary health care facilities. These refer their patients to the national referral hos-\npitals, including CHUK (public), and KFHR (private not-for-profit), supervised \nat the central level. Rwanda follows a universal healthcare model, which provides \nlow-cost community-based health insurance through the mutuelles de santé [18]. \nThis scheme allows residents to pay premiums tailored to their socio-economic \nclass to ensure that each citizen has access to medical care. Both CHUK and KFH \noffer advanced diagnostic services, including MRI, but advanced ART services are \nstill limited. \n2.2. Study Participant \nParticipants were recruited from outpatient gynaecology clinics at the selected \nhospitals. Women were eligible for recruitment if they were of reproductive age, \n18 - 45 years, with a confirmed surgical diagnosis of endometriosis, and willing to \noffer consent. Women with a history of other chronic gynaecological conditions \nthat may affect fertility (uterine fibroids, polycystic ovarian syndrome, primary \novarian insufficiency and chronic pelvic inflammatory disease) or any serious \ncomorbidities that may adversely affect the quality of life (such as multiple scle-\nrosis, schizophrenia, severe anxiety disorders, type 1 diabetes mellitus and condi-\ntions causing physical disabilities) were not included in this study. \n2.3. Sample Size and Sampling Procedure \nBased on the primary objective of comparing the impact of endometriosis between \nthe two countries, the sample size needed to detect a mean difference in scores of \nat least 5 with a standard deviation of 15 was calculated, with a power of 80% and \na 5% margin of error. A sample size of 142 per country was obtained. \nDuring the study period, at least two study contact persons were identified at \neach study site in China and Rwanda. These contact persons were stationed at \ntheir respective gynaecological clinics on clinic days and were responsible for \nscreening, consenting and interviewing of study participants. Participants were \nscreened consecutively against a set of eligibility criteria and, upon fulfilment, a \nquestionnaire was administered. \n2.4. Data Collection and Measurements \nData was collected using a validated 63-item Endometriosis Impact Questionnaire \n(EIQ). In Rwanda, the study contact persons were trained to use the English ver-\nsion during interviews without the need for translation, while in China, the tool \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 20 Yangtze Medicine \n \nwas first translated into Chinese, and it was self-administered. This tool captured \ndata on the burdens experienced by women over three recall periods: the last 12 \nmonths, 1 to 5 years ago, and more than 5 years ago. The EIQ uses a 5-point Likert \nscale scored as follows: Not at all = 0, A little = 1, Somewhat = 2, Quite a lot = 3, \nVery much = 4 and Not applicable = 9. The original tool defines six distinct do-\nmains of quality of life, including physical-psychosocial (33 items), fertility (3 \nitems), sexual (7 items), employment (11 items), educational (6 items), and life-\nstyle (3 items). In this study, the first domain (physical-psychosocial) was further \ndivided into physical (13 items), psychological (16 items) and social (4 items) do-\nmains, giving rise to a total of eight domains for a comprehensive assessment. \nEach domain contributes equally to the maximum score, and the overall score is \ncalculated by adding all applicable scores across the three recall periods. The total \nscore for each domain is calculated as the mean of the three recall periods. The \nscores are then rescaled to 0 - 100, with 0 indicating the minimum possible impact \nand 100 the maximum possible impact [19]. \nThe final data collection tool was designed to capture additional information \non sociodemographic characteristics and appropriate reproductive health, such as \na history of self-reported infertility. In this study, infertility was defined as history \nof delayed or difficulty in conception as reported by the participant, who was a \nsexually active woman of reproductive age. The data collection tools in English \nand Chinese were converted into electronic forms using Kobo Toolbox (Cam-\nbridge, MA, USA). \n2.5. Data Management and Analysis \nUpon completion of data collection, datasets were extracted from Kobo Toolbox \nand imported into Microsoft Excel for cleaning. The Chinese dataset was first \nback-translated with the help of the Google translation tool. After translation, \nboth Chinese and Rwandan datasets were merged to complete the cleaning pro-\ncess. Before analysis, each participant’s responses to the 63 -item EIQ were re-\nviewed, and total scores were systematically calculated as described in the pre-\nvious subsection. To facilitate a balanced c omparison, a participant’s periodic \nscore was calculated only if 50% of the items in the domain were answered, in \nline with the original developer’s recommendation [19]. The overall, periodic \nand domain scores  were subsequently transformed to a 0 - 100 scale using the \nformula: \n( )\nSum of scores of applicable itemsTransformed Total score 100Number of items answered 4= ××  \nAdditionally, the monthly income reported by participants was converted into \nUS dollars (USD) to allow for comparison across participants from both coun-\ntries. Conversion was completed using the prevailing dollar rate on November 1, \n2025, on the Oanda Corporate Smarter Services platform [20]. The exchange rates \nwere 1 Rwandan Franc (RWF) = 0.00069 USD and 1 Chinese Yuan Renminbi \n(CNY) = 0.14059 USD. \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 21 Yangtze Medicine \n \nDescriptive statistics were used to summarise sociodemographic and clinical \ncharacteristics, using medians and interquartile ranges (IQRs), while group com-\nparison was completed by use of the Mann-Whitney U test for continuous varia-\nbles, and the Chi-square test or Fisher’s exact test (for variables consisting of fre-\nquencies less than 10) for categorical variables. Continuous variables were assessed \nfor normality using visual inspection (histogram with normal overlay and kernel \ndensity plots) and statistical tests (Shapiro-Wilk and skewness-kurtosis tests). To \nidentify predictors of EIQ scores, the multiple linear regression model was used, \nwhile logistic regression was employed to examine factors associated with infer-\ntility. Model assumptions were verified, multicollinearity assessed (mean VIF = \n2.33), and significance set at p < 0.05. Results were presented with 95% confidence \nintervals. Data were analysed using Stata 15.0 (StataCorp, College Station, TX, \nUSA). \n3. Results \nOver the study period (January-November 2025), a total of 161 women with en-\ndometriosis were identified in the gynaecology outpatient clinics in China and \nRwanda (Figure 1 ). Of these, 8 (5.0%) women in China refused to consent, yield-\ning a total of 153 participants who completed the interviews and whose results \nwere analysed. \n \n \nFigure 1 . Study recruitment. \n3.1. Characteristics of Study Participants \nOf the 153 women who participated in the study, 102 (66.7%) were from China \n(Table 1 ). The median age was 31 years (interquartile range (IQR): 25 - 39), with \nChinese women significantly younger than their Rwandan counterparts (30 vs 35 \nyears; p = 0.009). \nMarked differences were observed in marital status; about two-thirds of Rwan-\n\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 22 Yangtze Medicine \n \ndan women (68.6%) were married compared with only 36.3% of Chinese partici-\npants (p < 0.001). Conversely, widowed status was more frequent among Chinese \nwomen (12.7%) and absent in Rwanda. Additionally, educational attainment dif-\nfered significantly, China having more women with tertiary education compared \nto Rwanda (51.0% vs 41.2%, p = 0.005). Almost half of all participants (47.7%) \nhad completed tertiary education. Employment rates were higher in China \n(85.3%) than in Rwanda (64.7%) (p = 0.004), despite a greater proportion of Chi-\nnese participants living in rural areas (62.7%) compared to Rwandans (47.1%). \nHousehold income varied markedly between countries (median = $674.8 in China \nvs $103.5 in Rwanda; p < 0.001). However, health insurance coverage was more \ncommon in Rwanda (84.3%) than in China (66.7%) (p = 0.022). \nRegarding reproductive history, out of the 153 women in this study, 73.9% were \nsexually active, with no difference between countries (p = 0.603). However, self-\nreported infertility was more frequent among Chinese participants than Rwan-\ndans (74.3% vs 41.0%; p < 0.001). In both countries, about 60% of women who \nreported infertility, also reported having accessed treatment (p > 0.999) (Table 1). \n \nTable 1 . Characteristics of study participants, N = 153. \nVariable  Overall  \nCountry of residence  \np-valuea \nChina (n  = 102) Rwanda (n  = 51) \nAge in years, median (interquartile range)  31 (25, 39) 30 (24, 36) 35 (28, 42) 0.009 \nMarital Status      \nMarried 72 (47.1) 37 (36.3) 35 (68.6) \n<0.001 \nSingle 50 (32.7) 38 (37.3) 12 (23.5) \nDivorced 18 (11.8) 14 (13.7) 4 (7.8) \nWidowed 13 (8.5) 13 (12.7) 0 (0.0) \nLevel of education      \nPrimary 24 (17.7) 15 (14.7) 9 (17.6) \n0.005 Secondary 56 (36.6) 35 (34.3) 21 (41.2) \nTertiary 73 (47.7) 52 (51.0) 21 (41.2) \nEmployment status      \nEmployed 120 (78.4) 87 (85.3) 33 (64.7) \n0.004 \nNot employed 33 (21.6) 15 (14.7) 18 (35.3) \nResidence type      \nRural 88 (57.5) 64 (62.7) 24 (47.1) \n0.064 \nUrban 65 (42.5) 38 (37.3) 27 (52.9) \nMonthly income (USD)  421.8 (103.5, 702.9) 674.8 (421.8, 843.5) 103.5 (3.5, 186.3) <0.001 \nHas insurance coverage      \nYes 111 (72.5) 68 (66.7) 43 (84.3) \n0.022 \nNo 42 (27.5) 34 (33.3) 8 (15.7) \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 23 Yangtze Medicine \n \nContinued  \nSexually active      \nYes 113 (73.9) 74 (72.5) 39 (76.5) \n0.603 \nNo 40 (26.1) 28 (27.5) 12 (23.5) \nReported history of infertility      \nYes 71 (62.8) 55 (74.3) 16 (41.0) \n<0.001 \nNo 42 (37.2) 19 (25.7) 23 (59.0) \nReceived fertility treatment      \nYes 43 (38.1) 33 (60.0) 10 (62.5) \n>0.999 \nNo 28 (24.8) 22 (40.0) 6 (37.5) \nUSD = United States Dollar. aThe p-values were estimated with Chi-square or Exact Fisher’s test for categorical variables and Mann-\nWhitney U test for continuous variables. \n3.2. Impact of Endometriosis on the Quality of Life among Study \nParticipants \nThe overall median EIQ impact score was 43.3 (IQR 14.2 - 58.5), with no signifi-\ncant difference between countries (p = 0.549). Likewise, there was no statistical \ndifference across the three recall periods, that is, median = 47.3 (24.6 - 63.2), p = \n0.328 for less than 12 months period, median = 42.5 (15.9 - 60.9), p = 0.411 for 1 \n- 5 years period and median = 0 (0.0 - 50.9), p = 0.215 for more than 5 years period \n(Table 2 ). \n \nTable 2 . Endometriosis Impact Scores for the different recall periods among study participants in China and Rwanda, N = 153. \nRecall period  Overall  \nCountry of residence  \np-value \nChina (n  = 102) Rwanda (n  = 51) \nOverall (median (IQR)) 43.3 (14.2, 58.5) 43.5 (20.1, 55.9) 43.3 (8.1, 65.9) 0.549 \nLess than 12 months (median (IQR)) 47.3 (24.6, 63.2) 47.6 (29.4, 59.9) 40.5 (10.9, 69.1) 0.328 \n1 - 5 years (median (IQR)) 42.5 (15.9, 60.9) 41.6 (19.8, 56.1) 46.1 (10.9, 63.9) 0.411 \nMore than 5 years (median (IQR)) 0 (0.0, 50.9) 0 (0.0, 52.6) 0 (0.0, 45.6) 0.215 \nIQR = Interquartile range. \n \nHowever, as shown in Figure 2 , significant differences in the impact of endo-\nmetriosis on some domains were observed across countries, including sexual (me-\ndian score 23.8 vs 45.3, p = 0.016), fertility (median score 19.4 vs 61.8, p = 0.005) \nand lifestyle (median score 0 vs 0, p = 0.001). There was no statistical difference \nin the impact on the physical, psychological, social, educational and employment \ndomains. \nAfter adjusting for demographic and reproductive factors, country of residence \nwas not significantly associated with EIQ scores (β = 4.5, 95% CI: –8.2,17.1; p = \n0.484). Age, marital status, employment, income, and insurance coverage were \nalso non-significant (Table 3 ). However, education level emerged as a significant \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 24 Yangtze Medicine \n \nindependent predictor. Compared with women with primary level education, \nthose with secondary education (β = –13.6; 95% CI: –27.1, –0.1; p = 0.049) and \ntertiary education (β = –17.0; 95% CI: –31.5, –2.5; p = 0.022) reported significantly \nlower impact scores, indicating less impairment of quality of life. \n \n \nFigure 2 . Median scores by participants in the different domains assessed. p-values indicate between-country differences. \n \nTable 3 . Multiple linear regression model of the predictors of the overall endometriosis impact scores among participants. \nVariable  Coefficient ( β) Robust SE  95% CI Adjusted p -value \nCountry of residence      \nRwanda Reference    \nChina 4.5 6.4 −8.2, 17.1 0.484 \nAge in years  0.2 0.4 −0.5, 0.9 0.581 \nMarital status      \nSingle Reference    \nMarried −10.0 7.6 −25.0, 5.0 0.19 \nDivorced 6.7 8.3 −9.9, 23.2 0.427 \nWidowed −3.9 9.4 −22.5, 14.8 0.679 \nLevel of education      \nPrimary Reference    \nSecondary −13.6 6.8 −27.1, −0.1  0.049 \nTertiary −17.0 7.3 −31.5, −2.5  0.022 \nEmployment status      \nNot employed Reference    \nEmployed −1.1 6.1 −13.2, 11.1 0.863 \n\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 25 Yangtze Medicine \n \nContinued  \nIncome in USD  0.0 0.0  0.979 \nHas insurance coverage      \nNo Reference    \nYes −4.7 4.9 −14.4, 5.1 0.344 \nReported history of infertility      \nNo Reference    \nYes 2.9 5.1 −7.2, 13.0 0.567 \nSE = Standard error. \n3.3. Impact of Endometriosis on Fertility among Participants \nOut of the 113 sexually active women, 71 (62.8%) reported history of infertility. \nIn the unadjusted analysis, country of residence and income were significantly \nassociated with infertility. Chinese participants had over fourfold higher odds of \nreporting infertility compared with Rwandan women (cOR = 4.16; 95% CI 1.83 - \n9.49; p = 0.001). \nHowever, after adjusting for age, marital status, income, and insurance status, \nthe association with country was attenuated and no longer significant (aOR = 0.83; \n95% CI 0.20 - 3.51; p = 0.797). \nMonthly income remained a significant independent predictor (aOR = 1.002; \n95% CI: 1.000, 1.003; p = 0.034), suggesting that women with higher income levels \nwere more likely to report infertility. Health insurance showed a borderline pro-\ntective association (aOR = 0.35; 95% CI 0.12 - 1.03; p = 0.056), whereas age and \nmarital status were not significantly related to infertility (Table 4 ). \n \nTable 4 . Factors associated with a history of infertility among participants. \nVariable  cOR (95%  CI) p-value aOR (95%  CI) p-value \nAge in years  0.98 (0.930, 1.033) 0.455 0.97 (0.907, 1.037) 0.37 \nMarital status      \nSingle Reference    \nMarried 0.461 (0.132, 1.607) 0.224 0.429 (0.095, 1.938) 0.271 \nDivorced 1.2 (0.237, 6.065) 0.825 0.778 (0.116, 5.216) 0.796 \nWidowed 4.4 (0.418, 46.261) 0.217 2.922 (0.225, 37.987) 0.413 \nMonthly income in USD  1.002 (1.001, 1.003) 0.001 1.002 (1.000, 1.003) 0.034 \nCountry of residence      \nRwanda Reference    \nChina 4.161 (1.825, 9.487) 0.001 0.827 (0.195, 3.506) 0.797 \nHas insurance coverage      \nNo Reference    \nYes 0.417 (0.161, 1.081) 0.072 0.348 (0.118, 1.029) 0.056 \nUSD = United States Dollar; cOR = Crude Odds Ratio; aOR = Adjusted Odds Ratio. \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 26 Yangtze Medicine \n \n3.4. Fertility Treatment Modalities and Satisfaction \nAmong participants who experienced infertility (n = 71), 43 (60.5%) reported hav-\ning received at least one fertility treatment modality, 33 (76.7%) of whom were in \nChina. The most commonly reported modality across both countries was surgical \ninterventions reported by 12/33 women in China and 8/10 women in Rwanda \n(Figure 3 ). This was followed by In vitro fertilization (IVF) which was reported \nexclusively by Chinese women (11/33 reported having used it) and medical ther-\napy (e.g., clomiphene) reported by 9/33 Chinese and 2/10 Rwandan women and \nlastly intrauterine insemination (IUI) reported by 3/33 Chinese women. \nThe median satisfaction ratings across treatment modalities were 4 (IQR: 2 - 5) \namong Chinese women and 2 (IQR: 0 - 3) among Rwandan women.  \n \n \nFigure 3 . Treatment modalities received by participants for fertility. Participants also rated \nthe treatment received on a scale of 0 - 5. Provided are medians with interquartile ranges \nin parentheses. IVF = In Vitro Fertilization, IUI = Intrauterine Insemination. \n4. Discussion \nThis study compared the impact of endometriosis on quality of life (QoL) and \nfertility among women of reproductive age in two resource-diverse settings: China \nand Rwanda. Despite substantial sociodemographic and economic differences, the \noverall EIQ scores were comparable, indicating that endometriosis imposes a sig-\nnificant burden irrespective of healthcare infrastructure or income level. This \nfinding is not surprising, as previous studies have documented the substantial im-\npact of endometriosis in both low-resource and high-income settings, although \nmost were non-comparative in nature [21]. A similar comparative assessment by \nNnoaham E.K. and colleagues across economically and ethnically diverse coun-\ntries found consistently high disease burden, further exacerbated by prolonged \ndiagnostic delays characteristic of state-funded health systems [22]. Such delays \nare common in low-resource settings, including Rwanda, where healthcare is pre-\ndominantly state-funded. The lack of differences in QoL scores in our study may \ntherefore be partly explained by Rwanda’s community-based health insurance \n\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 27 Yangtze Medicine \n \nprogramme, which enhances financial sustainability and reduces out-of-pocket \nexpenditure, thereby improving access to care for affected women. However, it is \nimportant to note that insurance coverage does not necessarily eliminate indirect \neconomic barriers, such as transportation costs, loss of income, and limited access \nto specialised services, which may differentially affect specific QoL domains. \nNonetheless, these findings highlight the potential value of adopting similar in-\nsurance schemes in other low-resource countries to improve equitable access to \nessential health services. \nDespite comparable overall EIQ scores, domain-specific differences emerged, \nwith Rwandan women reporting lower impact in sexual, fertility, and lifestyle do-\nmains. These variations likely reflect contextual factors such as cultural percep-\ntions of infertility, marital expectations, and limited access to specialised repro-\nductive care. In addition, the marked income disparity between participants in \nChina and Rwanda may have acted as an important confounding factor influenc-\ning these domains. Economic constraints can limit access to fertility investiga-\ntions, assisted reproductive technologies, pain management options, and lifestyle-\nmodifying interventions, thereby shaping women’s experiences regardless of their \ncultural contexts [9]. Notably, the study found that higher education is a signifi-\ncant protective factor against the impact of endometriosis on QoL, a finding con-\nsistent with previous evidence [23]. Educated women may be better equipped to \nseek timely care, adopt effective coping strategies, and adhere to management \nplans, thereby reducing disease burden. In contrast, a similar study conducted in \nPoland reported an association between education and lower QoL, although in \nthat study, the effect was limited to the treatment domain [24]. This is rather not \nunexpected, as educated women may have higher expectations regarding treat-\nment standards and may be more easily frustrated by the limitations of current \nendometriosis care. The difference in findings is, therefore, likely due to the use \nof different measurement tools; the EIQ used in our study does not assess treat-\nment-related perceptions as a QoL domain. Although there are studies which have \nexplored the role of educational interventions in improving awareness, care-seek-\ning, and QoL among women with endometriosis, with promising outcomes [25] \n[26], there is little evidence that such strategies have been widely implemented. \nNonetheless, these studies show that integrating targeted educational programs \ncould help reduce diagnostic delays, improve treatment outcomes, and enhance \noverall QoL for affected women. Future studies should examine the feasibility, ac-\nceptability, and cost-effectiveness of implementing such programs to inform pol-\nicy and practice. \nOverall, 62.8% of women in our study reported having experienced infertility, \nwith significantly higher proportions among Chinese participants. This preva-\nlence far exceeds global estimates, which suggest a pooled infertility prevalence of \n12.8%, with slightly higher rates in Africa (16.3%) than in Asia (14.9%) [27]. How-\never, the strong association between endometriosis and infertility is well docu-\nmented, and likely explains the high infertility prevalence observed in this clinical \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 28 Yangtze Medicine \n \npopulation [28]. Because this was a hospital-based study, the lower proportion of \nreported infertility among Rwandan women may reflect underdiagnosis or cul-\ntural reluctance to disclose infertility rather than a true epidemiological differ-\nence. Previous literature highlights how stigma and social pressure, particularly \namong women from low socioeconomic backgrounds, can lead to nondisclosure \nor denial of infertility [29]-[32]. These insights highlight the need for fertility \ncounselling and screening programs that are both affordable and culturally sensi-\ntive. Clinicians should receive contextually relevant training to proactively screen \nwomen presenting with chronic pelvic pain or dysmenorrhea for infertility risk to \nsupport early diagnosis and disclosure. Moreover, the study also observed that \nwomen with higher income levels were more likely to report infertility. This is \nlikely because higher-income women are more able to access diagnostic evalua-\ntions and fertility services [33]. Population-level studies consistently show that \nhigher-income women tend to have lower infertility risk, due to better healthcare \naccess, healthier lifestyles, improved nutrition, and greater engagement in physi-\ncal activity, all factors associated with good reproductive health outcomes [34] \n[35]. However, it is worth noting that although higher income was statistically \nassociated with reported infertility in this study, the magnitude of effect per unit \nincrease was small and should be interpreted as indicative of access to diagnostic \nand fertility services rather than a clinically meaningful risk factor. Lastly, given \nthese were self-reported cases, infertility may have been over-estimated, poten-\ntially explaining the unusually high prevalence (74.3%) observed in the Chinese \ncohort. \nRegarding fertility treatment, marked differences were observed between the \ntwo countries. Chinese participants reported access to a wider range of interven-\ntions, including IVF, IUI, hormonal therapies, and surgery. In contrast, women \nin Rwanda primarily relied on medical or surgical management. This disparity \nmay be partly explained by the substantial income difference between the groups, \nwith Rwandan women earning a median of USD 103.5 per month compared to \nUSD 674.8 in China, making advanced reproductive therapies financially inacces-\nsible. Additionally, although Rwanda’s community-based health insurance model \nimproves access to general healthcare services, it does not cover ART services. \nFurthermore, ART services in Rwanda are limited to a few private-for-profit fa-\ncilities where a single IVF cycle costs approximately USD 5000, far beyond the \nmeans of most women [36]. While surgery and hormonal therapy may offer \nsymptomatic relief, they are associated with significant drawbacks. Surgical man-\nagement carries risks such as infertility, chronic pain, and urological, intestinal, \nvascular, or neurological complications [11] [12]. Hormonal therapies, likewise, \nare linked to recurrence of symptoms and adverse effects, including mood changes, \nweight gain, breast tenderness, headaches, and nausea [10] [37] [38]. These limi-\ntations may explain the lower treatment satisfaction reported by Rwandan women \ncompared with their Chinese counterparts. Although including ART within the \ncommunity-based insurance package may be financially challenging, strengthen-\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 29 Yangtze Medicine \n \ning public-private partnerships could help expand access to fertility services in \nRwanda and similar settings. Coupled with tailored reproductive health education \nprograms, such strategies could promote timely care-seeking, reduce diagnostic \ndelays, and ultimately improve treatment outcomes and overall well-being for \nwomen affected by endometriosis. \nLimitations of the Study \nThis study has some limitations that should be considered when interpreting the \nfindings. First, because this was a hospital-based study, participants may have \nbeen more health-conscious than the general population, which may limit repre-\nsentativeness. Nevertheless, the hospital setting provided the most reliable means \nof identifying women with a confirmed diagnosis of endometriosis, ensuring that \nthe questionnaire was administered to an appropriate target population. Second, \nthe EIQ captures experiences across three recall periods extending up to more \nthan five years, which may introduce recall bias. However, because recall-period-\nspecific analyses yielded similar results, the impact of recall bias was likely mini-\nmal. Lastly, the target sample size was not fully achieved, particularly in Rwanda, \nwhere only 51 women participated, reducing statistical power and could have im-\npacted the statistical reliability of the non-significant findings between countries. \n5. Conclusion \nThis study demonstrates that women with endometriosis in China and Rwanda \nexperience a substantial burden on their quality of life, although the overall impact \ndoes not differ significantly between the two settings. However, notable domain-\nspecific variations were observed, with Rwandan women reporting lower impact \nin the sexual, fertility, and lifestyle domains, likely reflecting contextual di ffer-\nences in expectations, access to specialised care, and cultural perceptions. Educa-\ntion appears to play a protective role, with higher educational attainment associ-\nated with better QoL outcomes. Infertility remains a major concern in both coun-\ntries, yet access to advanced fertility treatments was limited in Rwanda, where sat-\nisfaction with care was also markedly lower. These findings highlight the need to \nstrengthen reproductive health education to improve timely care-seeking, and to \npromote public-private partnerships aimed at expanding access to assisted repro-\nductive technologies in Rwanda and similar low-resource settings. Strengthening \nthese areas may contribute to improved fertility outcomes and better quality of \nlife for women affected by endometriosis. \nAcknowledgements \nThe authors sincerely thank Dr.  Diomede Ntasumbumuyange and Dr . Vencent \nDusingizimana (University Teaching Hospital of Kigali), Dr . Briand Mvuyekure \nand Dr Jean Baptiste Muvunyi (King Faisal Hospital, Rwanda), Dr. Keming Chen \nand the team at Jingzhou First Hospital, and Dr Xiao Li (Jingzhou Central Hospi-\ntal) for their guidance and supervision. We are also grateful to Jean Pierre Ndayam-\n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 30 Yangtze Medicine \n \nbaje, Albertine Uwimfura and Niyonshuti Lambert for their assistance during data \ncollection in Rwanda. Our deepest appreciation goes to the study participants for \ntheir cooperation, without which this work would not have been possible. Finally, \nthe Principal Investigator thanks her husband, Dr Banak Abraham (Emergency \nMedicine Physician, Centre Hospitalier Nord Deux -Sèvres, Faye-l’Abbesse), for \nhis continuous encouragement and insightful support, which were invaluable  \nthroughout the research. \nEthics Approval and Consent to Participate \nThis study was conducted according to ethical principles as stated in the Declara-\ntion of Helsinki (1996) and applicable guidelines on Good Clinical Practice. Ap-\nproval was obtained from the Research and Ethics Committees of three hospitals \ninvolved in this study, with reference numbers: Jingzhou First People’s Hospital \n(IRB-AF/16-1.0), CHUK (EC/CHUK/042/2025) and KFH (KFH/2025/296/IRD). \nIn China, the approval from Jingzhou First People’s Hospital was deemed suffi-\ncient by the Jingzhou Central Hospital, where only administrative clearance to  \naccess the clinic was sought.  \nParticipants provided written informed consent to participate in the study and \nwere informed of their right to withdraw at will without any repercussions. Par-\nticipants’ identifiers, such as names, registration numbers or initials, were not cap-\ntured.  \nAvailability of Data and Materials \nThe datasets analysed in this study can be provided by the corresponding author \nupon reasonable request. \nFunding \nThis research was supported by the Hubei Provincial Natural Science Foundation \nProgram (Grant No. 2025AFC132) and the Jingzhou City Joint Scientific Research \nFoundation Project (Grant No. 2024LHY22). The funders had no role in study \ndesign, data collection and analysis, decision to publish, or preparation of the  \nmanuscript. \nAuthors’ Contribution \nFI conceived the study idea. FI and CY designed the methodology. FI, and SLD \noversaw data collection activities. FI drafted the manuscript while SLD, HW, QSZ \nand CY critically reviewed it. 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Reviews in Endocrine and Metabolic \nDisorders, 23, 333-355. https://doi.org/10.1007/s11154-021-09666-w \n[38] Davila, G.W., Kapoor, D., Alderman, E., Hiraoka, M.K.Y., Ghoniem, D.B., Ghoniem, \nG.M. and Peskin, B.D. (2023) Endometriosis Treatment & Management. Medscape.  \nhttps://emedicine.medscape.com/article/271899-treatment?form=fpf  \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n\nF. Irafasha et al. \n \n \nDOI: 10.4236/ym.2026.101003 34 Yangtze Medicine \n \nList of Abbreviations \nART: Assisted Reproductive Technologies \nCHUK: University Teaching Hospital of Kigali \nCNY: Chinese Yuan Renminbi \nEIQ: Endometriosis Impact Questionnaire \nFPHJ: First People’s Hospital of Jingzhou \nIQR: Interquartile Range \nIRB: Institutional Review Board \nIUI: Intrauterine Insemination \nIVF: In Vitro Fertilisation \nJCH: Jingzhou Central Hospital \nKFHR: King Faisal Hospital, Rwanda \nMRI: Magnetic Resonance Imaging \nQoL: Quality of Life \nRWF: Rwandan Franc \nUSD: United States Dollar","source_license":"CC0","license_restricted":false}