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, dysmenorrhea, 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 Questionnaire (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 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 countries, but IVF and IUI were accessed only in China, where satisfaction with care was higher (median 4 vs 2). Conclusion: Endometriosis substantially impairs 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 outcomes. Infertility was common, particularly among women with higher incomes, and