Isotria medeoloides plants may live for several years, remaining dormant for several years at a time (Mehrhoff 1989, Vitt 1991). Plants that remain dormant more than three years have a small probability of re-emerging (Vitt 1991). With few specialized structures or scents to attract insect pollinators, plants appear to be primarily self-pollinating (Mehrhoff 1983). Seed production is characterized as low to moderate, with 9,600 seeds produced by one plant (Mehrhoff 1983), but reproduction is generally efficient due to the orchid's capacity for self-fertilization (Vitt and Campbell 1997). Although multiple stems can arise from a single rootstock, Isotria medeoloides does not reproduce vegetatively (Mehrhoff 1983). Taller plants with a larger whorl diameter tend to flower more frequently than smaller plants (Mehrhoff 1989), and may emerge somewhat earlier in the year (Brumback and Fyler 1988). Plants emerge in May at the northern edge of the orchid's range, and in April farther south. Flowers can be maintained from several days to two weeks (Homoya 1977, Mehrhoff 1983). The fruit capsule matures in the fall. Dust-like orchid seeds often disperse by wind from the parent plant, but precise dispersal mechanisms are undescribed for this species.
There, associated species include Chestnut oak (Quercus prinus), tuliptree (Liriodendron tulipifera), white or Virginia pine (Pinus strobus or P. virginiana) that predominate in the canopy, blueberry species, New York fern (Thelypteris novaboracensis), the look-alike Medeola virginiana, ferns, club mosses, low-lying evergreen forbs such as partridgeberry (Mitchella repens), a shrub layer of witch hazel (Hamamelis virginiana), and frequently a canopy of paper birch (Betula papyrifera) (NatureServe 2001, (Patrick et al. 1995).
Recent research has found that the abundance of Russulaceae, both in the soil and on nearby ECM root tips, was significantly related to orchid prior emergence. Both abundance and prior emergence history were predictive of future emergence (Rock-Blake et al 2017).