Impact of Endometriosis on Fertility and Quality of Life among Women of Childbearing Age: A Comparative Hospital-Based Cross-Sectional Study in China and Rwanda

Background: Endometriosis is associated with chronic pelvic pain, dysmen- orrhea, and infertility, leading to substantial healthcare costs and diminished quality of life (QoL). While early diagnosis may improve outcomes, little is known about women’s experiences across resource-diverse settings. This study compared the impact of endometriosis on fertility and QoL among women of reproductive age in China and Rwanda. Methods: A cross-sectional study was conducted from January to November 2025 in four hospitals across China and Rwanda. Women aged 18 - 45 years with surgically confirmed endometriosis were enrolled, excluding those with comorbidities affecting infertility or QoL. Data were collected using the validated 63-item Endometriosis Impact Ques- tionnaire (EIQ). Multiple linear regression identified predictors of EIQ scores, and logistic regression assessed factors associated with self-reported infertility, using a 5% significance level. Results: Among 153 participants, 66.7% were from China; median age was 31 years (IQR: 25 - 39), and 47.7% had tertiary education. Median monthly income was higher in China than Rwanda ($674.8 vs $103.5; p < 0.001), while health insurance coverage was higher in Rwanda (84.3% vs 66.7%; p = 0.022). Of 113 sexually active women, 62.8% reported infertility, more frequently in China (74.3% vs 41.0%; p < 0.001). The overall median EIQ score was 43.3 (IQR 14.2 - 58.5), with no significant difference between countries across recall periods. However, Rwandan women reported lower impact in the fertility, sexual, and lifestyle domains (p < 0.05), while no differences were observed in physical, psychological, social, educational, or employment domains. After adjusting for confounders, country of residence How to cite this paper: Irafasha, F., Wei, H., Donasiao, S.L., Zeng, Q.S. and Yi, C.J. (2026) Impact of Endometriosis on Fertility and Quality of Life among Women of Childbearing Age: A Comparative Hospi- tal-Based Cross-Sectional Study in China and Rwanda. Yangtze Medicine, 10, 16-34. https://doi.org/10.4236/ym.2026.101003 Received: January 11, 2026 Accepted: March 7, 2026 Published: March 10, 2026 Copyright © 2026 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access F. Irafasha et al. DOI: 10.4236/ym.2026.101003 17 Yangtze Medicine did not predict EIQ scores (β = 4.5; p = 0.484), whereas secondary (β = –13.6; p = 0.049) and tertiary education (β = –17.0; p = 0.022) were associated with lower impact scores. Higher income was associated with reported infertility (aOR = 1.002; p = 0.034). Surgical management was common in both coun- tries, but IVF and IUI were accessed only in China, where satisfaction with care was higher (median 4 vs 2). Conclusion: Endometriosis substantially im- pairs the QoL of women in both China and Rwanda, with no differences in overall impact between the two settings. However, domain-specific variations were observed, and higher education was associated with better QoL out- comes. Infertility was common, particularly among women with higher in- comes, and advanced fertility treatments were accessible only in China, where satisfaction with care was also higher. These findings highlight the need to strengthen diagnostic capacity, expand fertility services, and improve compre- hensive endometriosis care, especially in resource-limited settings.

Endometriosis, Fertility, Quality of Life, Reproductive Health, Endometriosis Impact Questionnaire 1. Background Endometriosis is a chronic gynaecological condition characterised by the presence of endometrial tissue outside the uterus [1]. It is one of the most common gynae- cological conditions affecting over 10% of women of reproductive age globally [2]. Because of its insidious onset, a substantial number of cases remain undiagnosed, and its epidemiology is said to be underreported [3]. Nonetheless, literature indi- cates that over 30% - 50% of the affected women experience infertility [4], while many others suffer chronic pelvic pain, dysmenorrhea, and dyspareunia, which affect their quality of life [5] [6]. Diagnostic delays remain a defining challenge, with studies reporting an aver- age lag of 7 - 10 years between symptom onset and confirmed diagnosis [7] [8]. These delays often arise from nonspecific symptoms, normalisation of menstrual pain, and limited healthcare provider awareness [9]. Such barriers are particularly prevalent in low-resource settings like Rwanda, where specialised gynaecological services and advanced diagnostic technologies remain scarce. More industrialised countries, such as China, have better healthcare infrastructure, but disparities in timely diagnosis and treatment outcomes persist. Even where care is accessible, treatment options like surgery and hormonal therapy are often associated wit h varying success and may be accompanied by recurrence, side effects, or complica- tions such as infertility and chronic pain [10]-[12]. These challenges present a substantial toll on the overall physical, social, men- tal, and psychological well-being of women, thus negatively affecting the overall quality of life (QoL). Studies have indicated that patients with endometriosis re- F. Irafasha et al. DOI: 10.4236/ym.2026.101003 18 Yangtze Medicine port higher rates of anxiety, depression, and social isolation than their peers [13], [14]. The burden also has economic implications due to lost productivity and costs associated with healthcare [15]. However, evidence shows that early, holistic man- agement can substantially improve women’s well-being and productivity [16] [17]. Although substantial research has been conducted on endometriosis globally, there remains a paucity of comparative studies examining the condition across diverse socio-cultural and healthcare settings. Rwanda and China provide unique contexts for such a study, given their contrasting healthcare systems, population demographics, and cultural attitudes toward reproductive health. This study was therefore conducted to address the gap by comparing the impact of endometriosis on fertility and quality of life in women of childbearing age in Rwanda and China. The study also explored fertility challenges, treatment options, and women’s per- ceptions of treatment effectiveness across these contrasting settings. Understand- ing these disparities is crucial for tailored interventions and policy recommenda- tions to improve care for women globally. In addition to existing literature, this study sheds more light on how healthcare systems, cultural attitudes, and socio- economic factors shape the experiences of women with endometriosis. 2. Methods 2.1. Study Design and Settings This was a quantitative cross-sectional study conducted across two economically diverse settings in China and Rwanda from January to November 2025. In each country, two facilities were purposively selected based on the diagnostic capacity and availability of a gynaecology outpatient clinic where participants could be sampled. In China, these facilities included The First People’s Hospital of Jingzhou (FPHJ) and Jingzhou Central Hospital (JCH), while in Rwanda, University Teach- ing Hospital of Kigali (CHUK) and King Faisal Hospital, Rwanda (KFHR) were selected. China is a fast-growing upper-middle-income country located in East Asia, with a total land area of approximately 9.6 million square kilometres and a population exceeding 1.4 billion people. The country has a tiered healthcare system compris- ing primary, secondary, and tertiary levels, with tertiary hospitals serving a s re- gional or national referral centres offering specialised and technologically advanced care. The present study was conducted in Jingzhou City, located in Hubei Prov- ince, Central China. Jingzhou has a population of over 5.5 million people and is a rapidly developing urban area with expanding industrial and educational infra- structure. Both FPHJ and JCH are tertiary-level referral and teaching hospitals affiliated with Yangtze University. These facilities provide a wide range of special- ist services, including advanced gynaecological and reproductive health care, and are equipped with modern diagnostic technologies such as laparoscopic surgery, magnetic resonance imaging (MRI), and assisted reproductive technologies (ART). China’s health system operates through a mixed model, combining government F. Irafasha et al. DOI: 10.4236/ym.2026.101003 19 Yangtze Medicine subsidies, social health insurance, and out-of-pocket payments. In contrast, Rwanda is a landlocked low-income country located in East Africa. It is a small country covering 10,169 square miles on the ground with an estimated population size of 14 million people. The public health sector in Rwanda is organ- ised into three levels (peripheral, intermediate and central) with each level having defined technical and administrative platforms. The peripheral level is at the dis- trict level, consisting of the district health offices with a district hospital, and pri- mary health care facilities. These refer their patients to the national referral hos- pitals, including CHUK (public), and KFHR (private not-for-profit), supervised at the central level. Rwanda follows a universal healthcare model, which provides low-cost community-based health insurance through the mutuelles de santé [18]. This scheme allows residents to pay premiums tailored to their socio-economic class to ensure that each citizen has access to medical care. Both CHUK and KFH offer advanced diagnostic services, including MRI, but advanced ART services are still limited. 2.2. Study Participant Participants were recruited from outpatient gynaecology clinics at the selected hospitals. Women were eligible for recruitment if they were of reproductive age, 18 - 45 years, with a confirmed surgical diagnosis of endometriosis, and willing to offer consent. Women with a history of other chronic gynaecological conditions that may affect fertility (uterine fibroids, polycystic ovarian syndrome, primary ovarian insufficiency and chronic pelvic inflammatory disease) or any serious comorbidities that may adversely affect the quality of life (such as multiple scle- rosis, schizophrenia, severe anxiety disorders, type 1 diabetes mellitus and condi- tions causing physical disabilities) were not included in this study. 2.3. Sample Size and Sampling Procedure Based on the primary objective of comparing the impact of endometriosis between the two countries, the sample size needed to detect a mean difference in scores of at least 5 with a standard deviation of 15 was calculated, with a power of 80% and a 5% margin of error. A sample size of 142 per country was obtained. During the study period, at least two study contact persons were identified at each study site in China and Rwanda. These contact persons were stationed at their respective gynaecological clinics on clinic days and were responsible for screening, consenting and interviewing of study participants. Participants were screened consecutively against a set of eligibility criteria and, upon fulfilment, a questionnaire was administered. 2.4. Data Collection and Measurements Data was collected using a validated 63-item Endometriosis Impact Questionnaire (EIQ). In Rwanda, the study contact persons were trained to use the English ver- sion during interviews without the need for translation, while in China, the tool F. Irafasha et al. DOI: 10.4236/ym.2026.101003 20 Yangtze Medicine was first translated into Chinese, and it was self-administered. This tool captured data on the burdens experienced by women over three recall periods: the last 12 months, 1 to 5 years ago, and more than 5 years ago. The EIQ uses a 5-point Likert scale scored as follows: Not at all = 0, A little = 1, Somewhat = 2, Quite a lot = 3, Very much = 4 and Not applicable = 9. The original tool defines six distinct do- mains of quality of life, including physical-psychosocial (33 items), fertility (3 items), sexual (7 items), employment (11 items), educational (6 items), and life- style (3 items). In this study, the first domain (physical-psychosocial) was further divided into physical (13 items), psychological (16 items) and social (4 items) do- mains, giving rise to a total of eight domains for a comprehensive assessment. Each domain contributes equally to the maximum score, and the overall score is calculated by adding all applicable scores across the three recall periods. The total score for each domain is calculated as the mean of the three recall periods. The scores are then rescaled to 0 - 100, with 0 indicating the minimum possible impact and 100 the maximum possible impact [19]. The final data collection tool was designed to capture additional information on sociodemographic characteristics and appropriate reproductive health, such as a history of self-reported infertility. In this study, infertility was defined as history of delayed or difficulty in conception as reported by the participant, who was a sexually active woman of reproductive age. The data collection tools in English and Chinese were converted into electronic forms using Kobo Toolbox (Cam- bridge, MA, USA). 2.5. Data Management and Analysis Upon completion of data collection, datasets were extracted from Kobo Toolbox and imported into Microsoft Excel for cleaning. The Chinese dataset was first back-translated with the help of the Google translation tool. After translation, both Chinese and Rwandan datasets were merged to complete the cleaning pro- cess. Before analysis, each participant’s responses to the 63 -item EIQ were re- viewed, and total scores were systematically calculated as described in the pre- vious subsection. To facilitate a balanced c omparison, a participant’s periodic score was calculated only if 50% of the items in the domain were answered, in line with the original developer’s recommendation [19]. The overall, periodic and domain scores were subsequently transformed to a 0 - 100 scale using the formula: ( ) Sum of scores of applicable itemsTransformed Total score 100Number of items answered 4= ×× Additionally, the monthly income reported by participants was converted into US dollars (USD) to allow for comparison across participants from both coun- tries. Conversion was completed using the prevailing dollar rate on November 1, 2025, on the Oanda Corporate Smarter Services platform [20]. The exchange rates were 1 Rwandan Franc (RWF) = 0.00069 USD and 1 Chinese Yuan Renminbi (CNY) = 0.14059 USD. F. Irafasha et al. DOI: 10.4236/ym.2026.101003 21 Yangtze Medicine Descriptive statistics were used to summarise sociodemographic and clinical characteristics, using medians and interquartile ranges (IQRs), while group com- parison was completed by use of the Mann-Whitney U test for continuous varia- bles, and the Chi-square test or Fisher’s exact test (for variables consisting of fre- quencies less than 10) for categorical variables. Continuous variables were assessed for normality using visual inspection (histogram with normal overlay and kernel density plots) and statistical tests (Shapiro-Wilk and skewness-kurtosis tests). To identify predictors of EIQ scores, the multiple linear regression model was used, while logistic regression was employed to examine factors associated with infer- tility. Model assumptions were verified, multicollinearity assessed (mean VIF = 2.33), and significance set at p < 0.05. Results were presented with 95% confidence intervals. Data were analysed using Stata 15.0 (StataCorp, College Station, TX, USA). 3. Results Over the study period (January-November 2025), a total of 161 women with en- dometriosis were identified in the gynaecology outpatient clinics in China and Rwanda (Figure 1 ). Of these, 8 (5.0%) women in China refused to consent, yield- ing a total of 153 participants who completed the interviews and whose results were analysed. Figure 1 . Study recruitment. 3.1. Characteristics of Study Participants Of the 153 women who participated in the study, 102 (66.7%) were from China (Table 1 ). The median age was 31 years (interquartile range (IQR): 25 - 39), with Chinese women significantly younger than their Rwandan counterparts (30 vs 35 years; p = 0.009). Marked differences were observed in marital status; about two-thirds of Rwan- F. Irafasha et al. DOI: 10.4236/ym.2026.101003 22 Yangtze Medicine dan women (68.6%) were married compared with only 36.3% of Chinese partici- pants (p < 0.001). Conversely, widowed status was more frequent among Chinese women (12.7%) and absent in Rwanda. Additionally, educational attainment dif- fered significantly, China having more women with tertiary education compared to Rwanda (51.0% vs 41.2%, p = 0.005). Almost half of all participants (47.7%) had completed tertiary education. Employment rates were higher in China (85.3%) than in Rwanda (64.7%) (p = 0.004), despite a greater proportion of Chi- nese participants living in rural areas (62.7%) compared to Rwandans (47.1%). Household income varied markedly between countries (median = $674.8 in China vs $103.5 in Rwanda; p < 0.001). However, health insurance coverage was more common in Rwanda (84.3%) than in China (66.7%) (p = 0.022). Regarding reproductive history, out of the 153 women in this study, 73.9% were sexually active, with no difference between countries (p = 0.603). However, self- reported infertility was more frequent among Chinese participants than Rwan- dans (74.3% vs 41.0%; p 0.999) (Table 1). Table 1 . Characteristics of study participants, N = 153. Variable Overall Country of residence p-valuea China (n = 102) Rwanda (n = 51) Age in years, median (interquartile range) 31 (25, 39) 30 (24, 36) 35 (28, 42) 0.009 Marital Status Married 72 (47.1) 37 (36.3) 35 (68.6) <0.001 Single 50 (32.7) 38 (37.3) 12 (23.5) Divorced 18 (11.8) 14 (13.7) 4 (7.8) Widowed 13 (8.5) 13 (12.7) 0 (0.0) Level of education Primary 24 (17.7) 15 (14.7) 9 (17.6) 0.005 Secondary 56 (36.6) 35 (34.3) 21 (41.2) Tertiary 73 (47.7) 52 (51.0) 21 (41.2) Employment status Employed 120 (78.4) 87 (85.3) 33 (64.7) 0.004 Not employed 33 (21.6) 15 (14.7) 18 (35.3) Residence type Rural 88 (57.5) 64 (62.7) 24 (47.1) 0.064 Urban 65 (42.5) 38 (37.3) 27 (52.9) Monthly income (USD) 421.8 (103.5, 702.9) 674.8 (421.8, 843.5) 103.5 (3.5, 186.3) <0.001 Has insurance coverage Yes 111 (72.5) 68 (66.7) 43 (84.3) 0.022 No 42 (27.5) 34 (33.3) 8 (15.7) F. Irafasha et al. DOI: 10.4236/ym.2026.101003 23 Yangtze Medicine Continued Sexually active Yes 113 (73.9) 74 (72.5) 39 (76.5) 0.603 No 40 (26.1) 28 (27.5) 12 (23.5) Reported history of infertility Yes 71 (62.8) 55 (74.3) 16 (41.0) 0.999 No 28 (24.8) 22 (40.0) 6 (37.5) USD = United States Dollar. aThe p-values were estimated with Chi-square or Exact Fisher’s test for categorical variables and Mann- Whitney U test for continuous variables. 3.2. Impact of Endometriosis on the Quality of Life among Study Participants The overall median EIQ impact score was 43.3 (IQR 14.2 - 58.5), with no signifi- cant difference between countries (p = 0.549). Likewise, there was no statistical difference across the three recall periods, that is, median = 47.3 (24.6 - 63.2), p = 0.328 for less than 12 months period, median = 42.5 (15.9 - 60.9), p = 0.411 for 1 - 5 years period and median = 0 (0.0 - 50.9), p = 0.215 for more than 5 years period (Table 2 ). Table 2 . Endometriosis Impact Scores for the different recall periods among study participants in China and Rwanda, N = 153. Recall period Overall Country of residence p-value China (n = 102) Rwanda (n = 51) Overall (median (IQR)) 43.3 (14.2, 58.5) 43.5 (20.1, 55.9) 43.3 (8.1, 65.9) 0.549 Less 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 1 - 5 years (median (IQR)) 42.5 (15.9, 60.9) 41.6 (19.8, 56.1) 46.1 (10.9, 63.9) 0.411 More than 5 years (median (IQR)) 0 (0.0, 50.9) 0 (0.0, 52.6) 0 (0.0, 45.6) 0.215 IQR = Interquartile range. However, as shown in Figure 2 , significant differences in the impact of endo- metriosis on some domains were observed across countries, including sexual (me- dian score 23.8 vs 45.3, p = 0.016), fertility (median score 19.4 vs 61.8, p = 0.005) and lifestyle (median score 0 vs 0, p = 0.001). There was no statistical difference in the impact on the physical, psychological, social, educational and employment domains. After adjusting for demographic and reproductive factors, country of residence was not significantly associated with EIQ scores (β = 4.5, 95% CI: –8.2,17.1; p = 0.484). Age, marital status, employment, income, and insurance coverage were also non-significant (Table 3 ). However, education level emerged as a significant F. Irafasha et al. DOI: 10.4236/ym.2026.101003 24 Yangtze Medicine independent predictor. Compared with women with primary level education, those with secondary education (β = –13.6; 95% CI: –27.1, –0.1; p = 0.049) and tertiary education (β = –17.0; 95% CI: –31.5, –2.5; p = 0.022) reported significantly lower impact scores, indicating less impairment of quality of life. Figure 2 . Median scores by participants in the different domains assessed. p-values indicate between-country differences. Table 3 . Multiple linear regression model of the predictors of the overall endometriosis impact scores among participants. Variable Coefficient ( β) Robust SE 95% CI Adjusted p -value Country of residence Rwanda Reference China 4.5 6.4 −8.2, 17.1 0.484 Age in years 0.2 0.4 −0.5, 0.9 0.581 Marital status Single Reference Married −10.0 7.6 −25.0, 5.0 0.19 Divorced 6.7 8.3 −9.9, 23.2 0.427 Widowed −3.9 9.4 −22.5, 14.8 0.679 Level of education Primary Reference Secondary −13.6 6.8 −27.1, −0.1 0.049 Tertiary −17.0 7.3 −31.5, −2.5 0.022 Employment status Not employed Reference Employed −1.1 6.1 −13.2, 11.1 0.863 F. Irafasha et al. DOI: 10.4236/ym.2026.101003 25 Yangtze Medicine Continued Income in USD 0.0 0.0 0.979 Has insurance coverage No Reference Yes −4.7 4.9 −14.4, 5.1 0.344 Reported history of infertility No Reference Yes 2.9 5.1 −7.2, 13.0 0.567 SE = Standard error. 3.3. Impact of Endometriosis on Fertility among Participants Out of the 113 sexually active women, 71 (62.8%) reported history of infertility. In the unadjusted analysis, country of residence and income were significantly associated with infertility. Chinese participants had over fourfold higher odds of reporting infertility compared with Rwandan women (cOR = 4.16; 95% CI 1.83 - 9.49; p = 0.001). However, after adjusting for age, marital status, income, and insurance status, the association with country was attenuated and no longer significant (aOR = 0.83; 95% CI 0.20 - 3.51; p = 0.797). Monthly income remained a significant independent predictor (aOR = 1.002; 95% CI: 1.000, 1.003; p = 0.034), suggesting that women with higher income levels were more likely to report infertility. Health insurance showed a borderline pro- tective association (aOR = 0.35; 95% CI 0.12 - 1.03; p = 0.056), whereas age and marital status were not significantly related to infertility (Table 4 ). Table 4 . Factors associated with a history of infertility among participants. Variable cOR (95% CI) p-value aOR (95% CI) p-value Age in years 0.98 (0.930, 1.033) 0.455 0.97 (0.907, 1.037) 0.37 Marital status Single Reference Married 0.461 (0.132, 1.607) 0.224 0.429 (0.095, 1.938) 0.271 Divorced 1.2 (0.237, 6.065) 0.825 0.778 (0.116, 5.216) 0.796 Widowed 4.4 (0.418, 46.261) 0.217 2.922 (0.225, 37.987) 0.413 Monthly income in USD 1.002 (1.001, 1.003) 0.001 1.002 (1.000, 1.003) 0.034 Country of residence Rwanda Reference China 4.161 (1.825, 9.487) 0.001 0.827 (0.195, 3.506) 0.797 Has insurance coverage No Reference Yes 0.417 (0.161, 1.081) 0.072 0.348 (0.118, 1.029) 0.056 USD = United States Dollar; cOR = Crude Odds Ratio; aOR = Adjusted Odds Ratio. F. Irafasha et al. DOI: 10.4236/ym.2026.101003 26 Yangtze Medicine 3.4. Fertility Treatment Modalities and Satisfaction Among participants who experienced infertility (n = 71), 43 (60.5%) reported hav- ing received at least one fertility treatment modality, 33 (76.7%) of whom were in China. The most commonly reported modality across both countries was surgical interventions reported by 12/33 women in China and 8/10 women in Rwanda (Figure 3 ). This was followed by In vitro fertilization (IVF) which was reported exclusively by Chinese women (11/33 reported having used it) and medical ther- apy (e.g., clomiphene) reported by 9/33 Chinese and 2/10 Rwandan women and lastly intrauterine insemination (IUI) reported by 3/33 Chinese women. The median satisfaction ratings across treatment modalities were 4 (IQR: 2 - 5) among Chinese women and 2 (IQR: 0 - 3) among Rwandan women. Figure 3 . Treatment modalities received by participants for fertility. Participants also rated the treatment received on a scale of 0 - 5. Provided are medians with interquartile ranges in parentheses. IVF = In Vitro Fertilization, IUI = Intrauterine Insemination. 4. Discussion This study compared the impact of endometriosis on quality of life (QoL) and fertility among women of reproductive age in two resource-diverse settings: China and Rwanda. Despite substantial sociodemographic and economic differences, the overall EIQ scores were comparable, indicating that endometriosis imposes a sig- nificant burden irrespective of healthcare infrastructure or income level. This finding is not surprising, as previous studies have documented the substantial im- pact of endometriosis in both low-resource and high-income settings, although most were non-comparative in nature [21]. A similar comparative assessment by Nnoaham E.K. and colleagues across economically and ethnically diverse coun- tries found consistently high disease burden, further exacerbated by prolonged diagnostic delays characteristic of state-funded health systems [22]. Such delays are common in low-resource settings, including Rwanda, where healthcare is pre- dominantly state-funded. The lack of differences in QoL scores in our study may therefore be partly explained by Rwanda’s community-based health insurance F. Irafasha et al. DOI: 10.4236/ym.2026.101003 27 Yangtze Medicine programme, which enhances financial sustainability and reduces out-of-pocket expenditure, thereby improving access to care for affected women. However, it is important to note that insurance coverage does not necessarily eliminate indirect economic barriers, such as transportation costs, loss of income, and limited access to specialised services, which may differentially affect specific QoL domains. Nonetheless, these findings highlight the potential value of adopting similar in- surance schemes in other low-resource countries to improve equitable access to essential health services. Despite comparable overall EIQ scores, domain-specific differences emerged, with Rwandan women reporting lower impact in sexual, fertility, and lifestyle do- mains. These variations likely reflect contextual factors such as cultural percep- tions of infertility, marital expectations, and limited access to specialised repro- ductive care. In addition, the marked income disparity between participants in China and Rwanda may have acted as an important confounding factor influenc- ing these domains. Economic constraints can limit access to fertility investiga- tions, assisted reproductive technologies, pain management options, and lifestyle- modifying interventions, thereby shaping women’s experiences regardless of their cultural contexts [9]. Notably, the study found that higher education is a signifi- cant protective factor against the impact of endometriosis on QoL, a finding con- sistent with previous evidence [23]. Educated women may be better equipped to seek timely care, adopt effective coping strategies, and adhere to management plans, thereby reducing disease burden. In contrast, a similar study conducted in Poland reported an association between education and lower QoL, although in that study, the effect was limited to the treatment domain [24]. This is rather not unexpected, as educated women may have higher expectations regarding treat- ment standards and may be more easily frustrated by the limitations of current endometriosis care. The difference in findings is, therefore, likely due to the use of different measurement tools; the EIQ used in our study does not assess treat- ment-related perceptions as a QoL domain. Although there are studies which have explored the role of educational interventions in improving awareness, care-seek- ing, and QoL among women with endometriosis, with promising outcomes [25] [26], there is little evidence that such strategies have been widely implemented. Nonetheless, these studies show that integrating targeted educational programs could help reduce diagnostic delays, improve treatment outcomes, and enhance overall QoL for affected women. Future studies should examine the feasibility, ac- ceptability, and cost-effectiveness of implementing such programs to inform pol- icy and practice. Overall, 62.8% of women in our study reported having experienced infertility, with significantly higher proportions among Chinese participants. This preva- lence far exceeds global estimates, which suggest a pooled infertility prevalence of 12.8%, with slightly higher rates in Africa (16.3%) than in Asia (14.9%) [27]. How- ever, the strong association between endometriosis and infertility is well docu- mented, and likely explains the high infertility prevalence observed in this clinical F. Irafasha et al. DOI: 10.4236/ym.2026.101003 28 Yangtze Medicine population [28]. Because this was a hospital-based study, the lower proportion of reported infertility among Rwandan women may reflect underdiagnosis or cul- tural reluctance to disclose infertility rather than a true epidemiological differ- ence. Previous literature highlights how stigma and social pressure, particularly among women from low socioeconomic backgrounds, can lead to nondisclosure or denial of infertility [29]-[32]. These insights highlight the need for fertility counselling and screening programs that are both affordable and culturally sensi- tive. Clinicians should receive contextually relevant training to proactively screen women presenting with chronic pelvic pain or dysmenorrhea for infertility risk to support early diagnosis and disclosure. Moreover, the study also observed that women with higher income levels were more likely to report infertility. This is likely because higher-income women are more able to access diagnostic evalua- tions and fertility services [33]. Population-level studies consistently show that higher-income women tend to have lower infertility risk, due to better healthcare access, healthier lifestyles, improved nutrition, and greater engagement in physi- cal activity, all factors associated with good reproductive health outcomes [34] [35]. However, it is worth noting that although higher income was statistically associated with reported infertility in this study, the magnitude of effect per unit increase was small and should be interpreted as indicative of access to diagnostic and fertility services rather than a clinically meaningful risk factor. Lastly, given these were self-reported cases, infertility may have been over-estimated, poten- tially explaining the unusually high prevalence (74.3%) observed in the Chinese cohort. Regarding fertility treatment, marked differences were observed between the two countries. Chinese participants reported access to a wider range of interven- tions, including IVF, IUI, hormonal therapies, and surgery. In contrast, women in Rwanda primarily relied on medical or surgical management. This disparity may be partly explained by the substantial income difference between the groups, with Rwandan women earning a median of USD 103.5 per month compared to USD 674.8 in China, making advanced reproductive therapies financially inacces- sible. Additionally, although Rwanda’s community-based health insurance model improves access to general healthcare services, it does not cover ART services. Furthermore, ART services in Rwanda are limited to a few private-for-profit fa- cilities where a single IVF cycle costs approximately USD 5000, far beyond the means of most women [36]. While surgery and hormonal therapy may offer symptomatic relief, they are associated with significant drawbacks. Surgical man- agement carries risks such as infertility, chronic pain, and urological, intestinal, vascular, or neurological complications [11] [12]. Hormonal therapies, likewise, are linked to recurrence of symptoms and adverse effects, including mood changes, weight gain, breast tenderness, headaches, and nausea [10] [37] [38]. These limi- tations may explain the lower treatment satisfaction reported by Rwandan women compared with their Chinese counterparts. Although including ART within the community-based insurance package may be financially challenging, strengthen- F. Irafasha et al. DOI: 10.4236/ym.2026.101003 29 Yangtze Medicine ing public-private partnerships could help expand access to fertility services in Rwanda and similar settings. Coupled with tailored reproductive health education programs, such strategies could promote timely care-seeking, reduce diagnostic delays, and ultimately improve treatment outcomes and overall well-being for women affected by endometriosis.

of the Study This study has some limitations that should be considered when interpreting the findings. First, because this was a hospital-based study, participants may have been more health-conscious than the general population, which may limit repre- sentativeness. Nevertheless, the hospital setting provided the most reliable means of identifying women with a confirmed diagnosis of endometriosis, ensuring that the questionnaire was administered to an appropriate target population. Second, the EIQ captures experiences across three recall periods extending up to more than five years, which may introduce recall bias. However, because recall-period- specific analyses yielded similar results, the impact of recall bias was likely mini- mal. Lastly, the target sample size was not fully achieved, particularly in Rwanda, where only 51 women participated, reducing statistical power and could have im- pacted the statistical reliability of the non-significant findings between countries. 5. Conclusion This study demonstrates that women with endometriosis in China and Rwanda experience a substantial burden on their quality of life, although the overall impact does not differ significantly between the two settings. However, notable domain- specific variations were observed, with Rwandan women reporting lower impact in the sexual, fertility, and lifestyle domains, likely reflecting contextual di ffer- ences in expectations, access to specialised care, and cultural perceptions. Educa- tion appears to play a protective role, with higher educational attainment associ- ated with better QoL outcomes. Infertility remains a major concern in both coun- tries, yet access to advanced fertility treatments was limited in Rwanda, where sat- isfaction with care was also markedly lower. These findings highlight the need to strengthen reproductive health education to improve timely care-seeking, and to promote public-private partnerships aimed at expanding access to assisted repro- ductive technologies in Rwanda and similar low-resource settings. Strengthening these areas may contribute to improved fertility outcomes and better quality of life for women affected by endometriosis.

The authors sincerely thank Dr. Diomede Ntasumbumuyange and Dr . Vencent Dusingizimana (University Teaching Hospital of Kigali), Dr . Briand Mvuyekure and Dr Jean Baptiste Muvunyi (King Faisal Hospital, Rwanda), Dr. Keming Chen and the team at Jingzhou First Hospital, and Dr Xiao Li (Jingzhou Central Hospi- tal) for their guidance and supervision. We are also grateful to Jean Pierre Ndayam- F. Irafasha et al. DOI: 10.4236/ym.2026.101003 30 Yangtze Medicine baje, Albertine Uwimfura and Niyonshuti Lambert for their assistance during data collection in Rwanda. Our deepest appreciation goes to the study participants for their cooperation, without which this work would not have been possible. Finally, the Principal Investigator thanks her husband, Dr Banak Abraham (Emergency Medicine Physician, Centre Hospitalier Nord Deux -Sèvres, Faye-l’Abbesse), for his continuous encouragement and insightful support, which were invaluable throughout the research. Ethics Approval and Consent to Participate This study was conducted according to ethical principles as stated in the Declara- tion of Helsinki (1996) and applicable guidelines on Good Clinical Practice. Ap- proval was obtained from the Research and Ethics Committees of three hospitals involved in this study, with reference numbers: Jingzhou First People’s Hospital (IRB-AF/16-1.0), CHUK (EC/CHUK/042/2025) and KFH (KFH/2025/296/IRD). In China, the approval from Jingzhou First People’s Hospital was deemed suffi- cient by the Jingzhou Central Hospital, where only administrative clearance to access the clinic was sought. Participants provided written informed consent to participate in the study and were informed of their right to withdraw at will without any repercussions. Par- ticipants’ identifiers, such as names, registration numbers or initials, were not cap- tured. Availability of Data and Materials The datasets analysed in this study can be provided by the corresponding author upon reasonable request. Funding This research was supported by the Hubei Provincial Natural Science Foundation Program (Grant No. 2025AFC132) and the Jingzhou City Joint Scientific Research Foundation Project (Grant No. 2024LHY22). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors’ Contribution FI conceived the study idea. FI and CY designed the methodology. FI, and SLD oversaw data collection activities. FI drafted the manuscript while SLD, HW, QSZ and CY critically reviewed it. All authors read and approved the final manuscript. Conflicts of Interest The authors declare that they have no competing interests.

[1] Smolarz, B., Szyłło, K. and Romanowicz, H. (2021) Endometriosis: Epidemiology, F. Irafasha et al. DOI: 10.4236/ym.2026.101003 31 Yangtze Medicine Classification, Pathogenesis, Treatment and Genetics (Review of Literature). Interna- tional Journal of Molecular Sciences, 22, Article 10554. https://doi.org/10.3390/ijms221910554 [2] Zondervan, K.T., Becker, C.M. and Missmer, S.A. (2020) Endometriosis. The New England Journal of Medicine, 382, 1244-1256. https://doi.org/10.1056/NEJMra1810764 [3] Warzecha, D., Szymusik, I., Wielgos, M. and Pietrzak, B. (2020) The Impact of En- dometriosis on the Quality of Life and the Incidence of Depression— A Cohort Study. International Journal of Environmental Research and Public Health, 17, Article 3641. https://doi.org/10.3390/ijerph17103641 [4] Macer, M.L. and Taylor, H.S. (2012) Endometriosis and Infertility. Obstetrics and Gynecology Clinics of North America, 39, 535-549. https://doi.org/10.1016/j.ogc.2012.10.002 [5] Sachedin, A. and Todd, N. (2020) Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents. Journal of Clinical Research in Pediatric Endocrinology, 12, 7- 17. https://doi.org/10.4274/jcrpe.galenos.2019.2019.s0217 [6] Karp, B.I. and Stratton, P. (2023) Endometriosis-Associated Chronic Pelvic Pain. Med, 4, 143-146. https://doi.org/10.1016/j.medj.2023.02.006 [7] Saunders, P.T.K. and Horne, A.W. (2021) Endometriosis: Etiology, Pathobiology, and Therapeutic Prospects. Cell, 184, 2807-2824. https://doi.org/10.1016/j.cell.2021.04.041 [8] De Corte, P., Klinghardt, M., von Stockum, S. and Heinemann, K. (2025) Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics— A Systematic Literature Review. BJOG: An International Journal of Obstetrics and Gynaecology, 132, 118-130. [9] Harzif, A.K., Nurbaeti, P., Sayogo Putri, A., Silvana, V., Andyra, A.F. and Wiweko, B. (2024) Factors Associated with Delayed Diagnosis of Endometriosis: A Systematic Review. Journal of Endometriosis and Pelvic Pain Disorders. https://doi.org/10.1177/22840265241291120 [10] Cetera, G.E., Merli, C.E.M., Facchin, F., Viganò, P., Pesce, E., Caprara, F., et al. (2023) Non-Response to First-Line Hormonal Treatment for Symptomatic Endometriosis: Overcoming Tunnel Vision. A Narrative Review. BMC Women’s Health, 23, Article No. 347. https://doi.org/10.1186/s12905-023-02490-1 [11] Ceccaroni, M., Bounous, V.E., Clarizia, R., Mautone, D. and Mabrouk, M. (2019) Re- current Endometriosis: A Battle against an Unknown Enemy. The European Journal of Contraception & Reproductive Health Care, 24, 464-474. https://doi.org/10.1080/13625187.2019.1662391 [12] Ianieri, M.M., Mautone, D. and Ceccaroni, M. (2018) Recurrence in Deep Infiltrating Endometriosis: A Systematic Review of the Literature. Journal of Minimally Invasive Gynecology, 25, 786-793. https://doi.org/10.1016/j.jmig.2017.12.025 [13] Laganà, A.S., La Rosa, V.L., Rapisarda, A.M.C., Valenti, G., Sapia, F., Chiofalo, B., et al. (2017) Anxiety and Depression in Patients with Endometriosis: Impact and Manage- ment Challenges. International Journal of Women’s Health, 9, 323-330. https://doi.org/10.2147/ijwh.s119729 [14] van Stein, K., Schubert, K., Ditzen, B. and Weise, C. (2023) Understanding Psycho- logical Symptoms of Endometriosis from a Research Domain Criteria Perspective. Journal of Clinical Medicine, 12, Article 4056. https://doi.org/10.3390/jcm12124056 [15] Darbà, J. and Marsà, A. (2022) Economic Implications of Endometriosis: A Review. F. Irafasha et al. DOI: 10.4236/ym.2026.101003 32 Yangtze Medicine PharmacoEconomics, 40, 1143-1158. https://doi.org/10.1007/s40273-022-01211-0 [16] Dai, Y., Li, X., Shi, J. and Leng, J. (2018) A Review of the Risk Factors, Genetics and Treatment of Endometriosis in Chinese Women: A Comparative Update. Reproduc- tive Health, 15, Article No. 82. https://doi.org/10.1186/s12978-018-0506-7 [17] Mick, I., Freger, S.M., van Keizerswaard, J., Gholiof, M. and Leonardi, M. (2024) Comprehensive Endometriosis Care: A Modern Multimodal Approach for the Treat- ment of Pelvic Pain and Endometriosis. Therapeutic Advances in Reproductive Health, 18, 1-23. https://doi.org/10.1177/26334941241277759 [18] Nyandekwe, M., Nzayirambaho, M. and Kakoma, J.B. (2020) Universal Health Insur- ance in Rwanda: Major Challenges and Solutions for Financial Sustainability Case Study of Rwanda Community-Based Health Insurance Part I. Pan African Medical Journal, 37, Article 55. https://doi.org/10.11604/pamj.2020.37.55.20376 [19] Moradi, M., Parker, M., Sneddon, A., Lopez, V. and Ellwood, D. (2019) The Endo- metriosis Impact Questionnaire (EIQ): A Tool to Measure the Long-Term Impact of Endometriosis on Different Aspects of Women’s Lives. BMC Women’s Health, 19, Article No. 64. https://doi.org/10.1186/s12905-019-0762-x [20] Oanda (2025) Oanda Corporate FX Services. https://www.oanda.com/currency-converter/en/?from=EUR&to=USD&amount=1 [21] Maulenkul, T., Kuandyk, A., Makhadiyeva, D., Dautova, A., Terzic, M., Oshibayeva, A., et al. (2024) Understanding the Impact of Endometriosis on Women’s Life: An Integrative Review of Systematic Reviews. BMC Women’s Health, 24, Article No. 524. https://doi.org/10.1186/s12905-024-03369-5 [22] Nnoaham, K.E., Hummelshoj, L., Webster, P., d’Hooghe, T., de Cicco Nardone, F., de Cicco Nardone, C., et al. (2011) Impact of Endometriosis on Quality of Life and Work Productivity: A Multicenter Study across Ten Countries. Fertility and Sterility, 96, 366-373.e8. https://doi.org/10.1016/j.fertnstert.2011.05.090 [23] Jin, L., Chi, C., Zhang, Q., Zhang, Y., Han, G., Lin, J., et al. (2025) Effect of Education on Endometriosis and Mediating Effects: A Mendelian Randomization Study. AJOG Global Reports, 5, Article 100559. https://doi.org/10.1016/j.xagr.2025.100559 [24] Bień, A., Pokropska, A., Grzesik-Gąsior, J., Korżyńska-Piętas, M., Pieczykolan, A., Zarajczyk, M., et al. (2025) Quality of Life in Women with Endometriosis: The Im- portance of Socio-Demographic, Diagnostic-Therapeutic, and Psychological Factors. Journal of Clinical Medicine, 14, Article 4268. https://doi.org/10.3390/jcm14124268 [25] Bush, D., Brick, E., East, M.C. and Johnson, N. (2017) Endometriosis Education in Schools: A New Zealand Model Examining the Impact of an Education Program in Schools on Early Recognition of Symptoms Suggesting Endometriosis. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57, 452-457. https://doi.org/10.1111/ajo.12614 [26] Khan, K.N., Ogawa, K., Iwasa, K., Kuroboshi, H., Okimura, H., Koshiba, A., et al. (2022) A Targeted Educational Programme Improves Fundamental Knowledge of Menstrual Pain and Endometriosis in Young Women: The Endometriosis Awareness Promotion Project. Reproductive BioMedicine Online, 45, 1216-1229. https://doi.org/10.1016/j.rbmo.2022.07.009 [27] Zhu, H. et al. (2023) Global Prevalence of Infertility: A Systematic Review and Meta- Analysis of Community-Based Studies. Authorea. [28] Harris, A. and Tsaltas, J. (2017) Endometriosis and Infertility: A Systematic Review. Journal of Endometriosis and Pelvic Pain Disorders, 9, 139-149. https://doi.org/10.5301/jeppd.5000296 [29] Harzif, A.K., Santawi, V.P.A. and Wijaya, S. (2019) Discrepancy in Perception of In- F. Irafasha et al. DOI: 10.4236/ym.2026.101003 33 Yangtze Medicine fertility and Attitude towards Treatment Options: Indonesian Urban and Rural Area. Reproductive Health, 16, Article No. 126. https://doi.org/10.1186/s12978-019-0792-8 [30] Taebi, M., Kariman, N. and Majd, H.A. (2021) Infertility Stigma: A Qualitative Study on Feelings and Experiences of Infertile Women. International Journal of Fertility and Sterility, 15, 189-196. [31] Slade, P., O’Neill, C., Simpson, A.J. and Lashen, H. (2007) The Relationship between Perceived Stigma, Disclosure Patterns, Support and Distress in New Attendees at an Infertility Clinic. Human Reproduction, 22, 2309-2317. https://doi.org/10.1093/humrep/dem115 [32] Zhang, F., Lv, Y., Wang, Y., Cheng, X., Yan, Y., Zhang, Y., et al. (2021) The Social Stigma of Infertile Women in Zhejiang Province, China: A Questionnaire-Based Study. BMC Women’s Health, 21, Article No. 97. https://doi.org/10.1186/s12905-021-01246-z [33] Iba, A., Maeda, E., Jwa, S.C., Yanagisawa -Sugita, A., Saito, K., Kuwahara, A., et al. (2021) Household Income and Medical Help-Seeking for Fertility Problems among a Representative Population in Japan. Reproductive Health, 18, Article No. 165. https://doi.org/10.1186/s12978-021-01212-w [34] van Wijk, D. (2024) Higher Incomes Are Increasingly Associated with Higher Fertil- ity: Evidence from the Netherlands, 2008-2022. Demographic Research, 51, 809-822. https://doi.org/10.4054/demres.2024.51.26 [35] Munakampe, M.N., Fwemba, I., Zulu, J.M. and Michelo, C. (2021) Association be- tween Socioeconomic Status and Fertility among Adolescents Aged 15 to 19: An Analysis of the 2013/2014 Zambia Demographic Health Survey (ZDHS). Reproduc- tive Health, 18, Article No. 182. https://doi.org/10.1186/s12978-021-01230-8 [36] Oskowitz, S.P., Rwiyereka, A.K., Rurangwa, T., Shepard, D.S., Rwamasirabo, E., Isaacson, K.B., et al. (2023) Infertility Services Integrated within the Maternal Health Department of a Public Hospital in a Low-Income Country, Rwanda. F&S Reports, 4, 130-142. https://doi.org/10.1016/j.xfre.2023.04.001 [37] Vannuccini, S., Clemenza, S., Rossi, M. and Petraglia, F. (2022) Hormonal Treatments for Endometriosis: The Endocrine Background. Reviews in Endocrine and Metabolic Disorders, 23, 333-355. https://doi.org/10.1007/s11154-021-09666-w [38] Davila, G.W., Kapoor, D., Alderman, E., Hiraoka, M.K.Y., Ghoniem, D.B., Ghoniem, G.M. and Peskin, B.D. (2023) Endometriosis Treatment & Management. Medscape. https://emedicine.medscape.com/article/271899-treatment?form=fpf F. Irafasha et al. DOI: 10.4236/ym.2026.101003 34 Yangtze Medicine List of Abbreviations ART: Assisted Reproductive Technologies CHUK: University Teaching Hospital of Kigali CNY: Chinese Yuan Renminbi EIQ: Endometriosis Impact Questionnaire FPHJ: First People’s Hospital of Jingzhou IQR: Interquartile Range IRB: Institutional Review Board IUI: Intrauterine Insemination IVF: In Vitro Fertilisation JCH: Jingzhou Central Hospital KFHR: King Faisal Hospital, Rwanda MRI: Magnetic Resonance Imaging QoL: Quality of Life RWF: Rwandan Franc USD: United States Dollar