Women's Use of Complementary and Alternative Medicine for Fertility Enhancement: A Review of the Literature

Abstract

Objectives:

The use of complementary and alternative medicine (CAM) has increased in Western countries, with women identified as the primary users. Women's use of CAM in reproductive health is well documented; however, little is known about the use of CAM to enhance fertility, despite anecdotal evidence that this is a growing trend in reproductive medicine. The objective of this review was to examine the literature on women's use of CAM to enhance fertility, focusing on prevalence, motivations for use, and how information is sourced.

Design:

A systematic search of multiple databases was conducted using key words and selection criteria.

Results:

A total of eight articles that met the selection criteria, published between 1990 and 2010, were found and included in the review. The articles were analyzed under five key themes: “user prevalence,” “user profile,” “motivation for use,” “expectations and satisfaction,” and “referral and information sources.” This review demonstrates important gaps in the evidence regarding women's use of CAM for fertility enhancement. There are no population-based studies with representative samples, no commonly accepted definitions of CAM research, and few studies describing women's motivations for and experiences of using CAM for fertility enhancement. Importantly, little is known about women's sources of information about CAM in this context.

Conclusions:

Nationally representative, population-based studies are required to fill the gaps in the evidence, provide prevalence rates, and inform policy and clinical practice.

Introduction

C omplementary and alternative medicine (CAM) includes a broad spectrum of modalities and therapies outside the domain of conventional medicine.¹ There has been a rise in the use of and expenditure on CAM as a health care option in Western countries over the past 2 decades, although the prevalence of use varies between and within countries and according to the definition of CAM used.^{2

–11} CAM use has steadily increased in the United States from 39% in 1990³ to 50% in 2007;⁴ in Australia from 50% in 1993⁷ to 69% in 2006;⁶ and in Germany from 52% in 1970 to 73% in 2002.⁵ Similar rates are reported in the United Kingdom,⁸ Switzerland,⁹ and Japan.¹⁰ Forty-four percent (44%) of Australians consulted a CAM practitioner in 2006,⁶ which is a 20% increase since 1993,⁷ almost the same as the annual number of visits to medical practitioners.¹² Out-of-pocket expenses for CAM use in the United States were estimated to be $US27 billion in 2007, with $US12.2 billion spent on visits to CAM practitioners.¹¹ In Australia, expenditure on CAM in 2005 was $AUD4.13 billion,⁶ with $AUD85 million spent on visits to naturopaths and herbalists (excluding the costs of medicines) in 2004.¹³ Information about CAM is commonly obtained from nonmedical sources including family and friends, magazines, and increasingly the Internet.^14,15

In line with international trends,^4,8
–10,16 the Australian literature^6,17 shows that CAM users are more likely to be women, who are well-educated, employed with higher-than-average incomes, with private health insurance. CAM use by Australian women includes consultations with practitioners (38%) and self-medication with over-the-counter (OTC) CAM supplements (66%) or nonprescription medications (50%).¹⁸ In 2006, 75% of Australian women of reproductive age used some form of CAM,⁶ and in line with the international evidence,^19

–24 Australian women use CAM during pregnancy.^25

–28 There is also some evidence to show that Australian women are using nonprescribed medicines and OTC supplements prior to becoming pregnant.^26,27,29,30

In 2006, 1 in 6 Australian women of reproductive age who tried to conceive or had been pregnant reported infertility. Of these, 72% sought medical advice and 50% used assisted reproductive technologies (ART).³¹ The increased availability of diagnostic and treatment modalities³² and trends in women's older age at first birth³³ suggest that more couples may now be using fertility treatments to achieve parenthood than previously. The increased demand for fertility treatment in Australia is evidenced by both a 54% rise in the number of ART cycles, the growing proportion of births attributed to ART over the past decade,³⁴ and the escalating number of claims for rebates for these services among women aged 35–44 years.³⁵ The costs associated with achieving a live birth with ART increase substantially with advancing maternal age³⁶; however, the success of ART declines.³⁷ Despite differences in the funding arrangements for ART, the international evidence is similar to the Australian experience with regard to maternal age and increased prevalence of use.^38
–40 These facts, coupled with the reported negative experiences of ART⁴¹ that are associated with discontinuation of these regimens,⁴² may provide some understanding of women's increasing use of CAM for fertility enhancement.

This evidence points to important gaps in knowledge about women's use of CAM for fertility enhancement. The objective of the current literature review was to identify existing studies in this area and is intended to provide the basis for identifying gaps in the evidence pointing to areas for future research. The social pressures and psychologic stress associated with involuntary childlessness that encourages women to “try anything” must also be acknowledged.^29,43 However, little is known about the use of CAM for fertility enhancement, in particular the prevalence of use, the profile of users and their motivation, expectations and satisfaction, or the information sources consulted. There is also some concern about women's use of CAM by medical specialists because of the limited evidence of the safety and efficacy of many CAM regimens.³⁰ A Dutch study of treatment intentions among infertile couples found less than 20% selected CAM as an option after conventional medical help (86%), adoption (35%), and change in life goals (35%).⁴⁴ Danish women who use CAM in conjunction with ART had a 30% lower rate of pregnancy.⁴⁵ This article seeks to address this gap in knowledge by systematically reviewing current studies.

Methods

Design

A systematic review of the literature investigating CAM use for fertility enhancement was undertaken focusing on five themes: the prevalence of user, user profile, motivation for use, expectations and satisfaction with use, and referral and information sources.⁴⁶

Search strategy

A database search was conducted using MEDLINE,^® CINAHL, AMED, and PubMed. The search was confined to peer-reviewed articles published in English. Search strategies included using single and combinations of key words including: complementary medicine(s), alternative medicine(s), natural medicine(s), traditional medicine(s), non-conventional medicine(s), herbal medicine(s) with therapy and modality; as well as naturopathy, acupuncture, western herbal medicine; infertility, sub-fertility, fertility; enhancement, care, and treatment(s). Excluded from the review were letters to the editor, commentaries, case-study reports, clinical studies, and randomized controlled trials reporting specific therapeutic treatments or regimens.

Results

A total of eight articles, published between 1990 and 2010, met the selection criteria and were included in the review. A summary of the details of these articles with respect to the themes is presented in Table 1.

Table 1.

Details of Article in Literature Review

						Themes
Country	Author/year/ref.	Focus of study	CM modalities	Method	Sample characteristics	I	II	III	IV	V
United States	Galst 1999⁴⁸	Prevalence of, reasons for, & types of CM used	Vitamins, herbs, counseling, mind–body/meditation, exercise, acupuncture	Survey	n=46 Individuals (43 women, 3 men) attending an infertility clinic	✓	✓	✓	✓
United States	Schaffir et al. 2009⁴⁹	Prevalence, types & determinants of CM use	Religious interventions, nutritional advice, relaxation, herbal medicines, acupuncture	Survey	n=133Women attending private fertility clinic	✓	✓	✓	✓	✓
United States	Smith et al. 2010⁴⁶	Prevalence & predictors of CM use	Acupuncture, herbal medicines, massage, chiropractic, TCM, meditation	Interviews & questionnaires	n=428Women attending eight community & academic infertility clinics	✓	✓	✓
Australia	Stankiewicz et al. 2007⁵⁰	Prevalence of CM use	Mineral & vitamin supplements, herbal medicines, naturopathy, acupuncture, chiropractors	Survey	n=100Women attending fertility clinic	✓	✓			✓
Australia	Rayner et al. 2009²⁹	Prevalence of & motivations for CM use	Acupuncture, naturopathy, herbal medicines, supplements, yoga, meditation, TCM, reflexology, hypnotherapy, kinesiology	Focus groups	n=14One focus group of CAM practitioners (n=8); two focus groups of women using CAM (n=7)	✓	✓	✓	✓	✓
England	Coulson et al. 2005⁵¹	Prevalence of CM use	Nutritional advice, reflexology, acupuncture, TCM, herbal medicine, hypnosis, spiritual healing	Survey	n=338Couples attending National Health Service fertility clinic (n=181); private fertility clinic (n=157)	✓	✓		✓
Ireland	Shannon et al. 2010⁵²	Prevalence of herbal medicine use	Herbal medicines	Survey	n=113Women undergoing anesthesia for ART procedures	✓
Turkey	Edirne 2010⁵³	Prevalence of & types of CM used	Religious interventions, herbal medicines, traditional faith healers	Face-to-face questionnaire	n=100Women attending family planning clinic for infertility care	✓	✓

Themes: I, prevalence of use; II, user profile; III, motivations for use; IV, expectations of & satisfaction with; V, referral & information source; CM, complementary and alternative medicine; TCM, Traditional Chinese Medicine; ART, assisted reproductive technologies.

Characteristics of studies

The eight studies included in the review spanned the years 1999–2010. The study populations and sample sizes varied considerably. Three (3) studies were conducted in the United States,^47
–49 two in Australia,^29,50 with single studies conducted in England,⁵¹ Ireland,⁵² and Turkey.⁵³ Most of the study participants were recruited from infertility^47

–51 or family planning clinics⁵³ or while undergoing ART treatments⁵² with only one group recruited from a CAM practice.²⁹ Participant numbers ranged from 7 women participating in an Australian focus group study²⁹ to 423 couples attending eight community and academic infertility clinics in United States.⁴⁷ Various types of CAM were reported, including nutritional advice and the use of vitamins and minerals (either OTC and prescribed), herbal products, acupuncture, reflexology, Traditional Chinese Medicine, and traditional faith healers, spiritual healings and religious interventions, meditation, hypnosis, yoga, exercise, naturopathy, kinesiology, mind–body techniques, counseling and/or support groups, and chiropractic. The findings from the eight studies are presented under the key themes that framed the literature review.

Prevalence of CAM use for fertility enhancement/care

All eight studies reviewed provided details on the prevalence of CAM use for fertility enhancement. The proportion of women or couples using CAM for fertility enhancement varied considerably from 29%⁴⁷ to 91%.⁴⁸ The most common CAM used in fertility enhancement were herbal medicines, which was reported in all articles,^{29,47

–53} along with acupuncture,^{29,47

–51} and nutritional advice including the use of supplements.^29,48

–51 More unusual types interventions reported as CAM were the use of religious interventions and spiritual healing,^49,51,53 the wearing of fertility accessories,^49,53 and changes in attire and sexual practices.⁴⁹

CAM user profile

All but one study⁵² provided a profile of users of CAM for fertility enhancement. The profile of CAM users was similar across all studies but one⁵³ and correlated well with the general literature on CAM users^6,11,54 and with women's use in pregnancy.⁴⁶ Users of CAM for fertility enhancement are typically women who are older (median age 35 years^{29,47

–51,53} [range 26.7 years⁵³–40 years²⁹]), with high educational attainment,^29,47

–50 working as professionals and earning high incomes.^29,47,48,51 While some studies did not report directly on income,^29,52,51 the inclusion of private health insurance status can be seen as a proxy for income, reflecting ability to pay. The profile of CAM users differed in the Turkish study,⁵³ where women were younger (mean age 26.7 years, range 18–40 years) and their educational and economic status was reported as low. Additional associations with CAM use for fertility enhancement included the number of years trying to conceive and concurrent or past use of conventional medical technologies. Women who used CAM had been trying to conceived for a longer period of time^29,47,48,53 and were concurrently using or had previously used ART without success.^29,47

–50

Motivations for use

Four (4) studies reported on motivations for using CAM for fertility enhancement^29,47
–49 and one raised motivations in the discussion.⁵¹ Women who use CAM for fertility enhancement have often been unsuccessful in achieving a pregnancy with ART and have a positive attitude to the benefits of CAM use. It was reported that women used CAM in conjunction with ART to maximize their chances of becoming pregnant,^29,47,49,51 often after unsuccessful use of^29,49 or dissatisfaction with ART.^29,48 Other motivations reported included the improved quality of life and better health and well-being associated with CAM use^29,48,51; the positive relationship with CAM practitioners^29,51; and the supplemental use of CAM with conventional treatments.⁵¹ Previous CAM use was reported as a possible proxy for motivation,^47,49 and women also reported using CAM to regain control over their bodies.^29,48

Expectations of and satisfaction with CAM use for fertility enhancement

Only two of the studies reported on women's expectations of and satisfaction with CAM used for fertility enhancement.^29,51 Australian women reported that their decisions to use CAM for fertility enhancement had proved to be empowering and that specific treatments were beneficial in improving their health, but it was the relationships with CAM practitioners that were the most satisfying and affirming, especially when compared to the often difficult relationships with conventional medical fertility specialists.²⁹ English study participants were skeptical about the benefit of CAM for fertility enhancement, although most thought it had been helpful psychologically (13%) and for relaxation (22%).⁵¹

Referral and information source

Three (3) studies reported on the information sources used by participants,^29,49,50 with medical professionals reported as the most important source of information of all. In Australia, study participants reported having discussed the use of CAM with their general practitioners (31%) and/or fertility specialists (26%), with family members (22%), friends (16%), and CAM providers (14%), who were also reported as being influential in the decision to use CAM.⁵⁰ The Internet was also reported as a source of information in Australia and the United States,^29,49,50 accounting for 10% of responses in one Australian study.⁵⁰ Other media was also cited as being an influence source of information in the United States,⁴⁹ and in Australia, television (5%) and magazines (6%) were reported as information sources by women.⁵⁰

Discussion

Eight (8) articles that met the selection criteria published between 1990 and 2010 were analyzed under five key themes: user prevalence, user profile, motivation for use, expectations and satisfaction, and referral and information sources. The findings demonstrate important gaps in the evidence regarding women's use of CAM for fertility enhancement because there are no population-based studies with representative samples, no commonly accepted definitions of CAM, and few studies describing women's motivations or experiences of using CAM for fertility enhancement. Importantly, little is known about women's sources of information about CAM in this context.

The variety of studies reviewed in this article provide some interesting insights into the prevalence of CAM use for fertility enhancement, the profile of users, and their motivations and information sources. The proportion of women attending fertility clinics who also use CAM for fertility enhancement ranged from 29% to 91%. The main CAM modalities used were herbal medicines, acupuncture, and nutritional advice, including the use of supplements. The typical user profile of CAM users for maximizing chances of conceiving was women who were older, who had both high educational attainment and high income, and who used CAM to maximize their chances of conceiving. In general, the level of satisfaction with CAM use for fertility enhancement was high, mainly because of the benefits of empowerment, relaxation, and well-being.

Nonetheless, the studies are limited in the amount of information they provide. The limitations relate to sampling from statistically different populations, small sample sizes, and the use of a nonuniform definition of CAM. Participants were recruited mainly from fertility clinics, and thus there is no population-based information about the use of CAM for fertility enhancement. In particular, very little is still known about those women who purchase CAM products OTC or online, or who only seek assistance from CAM practitioners for fertility enhancement, and none of the articles report on any costs associated with CAM use for fertility enhancement. The methodological limitations of many studies make it difficult to estimate and compare prevalence of CAM use within and between countries.

The literature reviewed is valuable as it indicates that there are similarities between CAM use in the general health literature and its use for fertility enhancement. This is particularly the case with studies reporting on motivations for CAM use and user profiles.⁵⁴ However, much more knowledge is needed. Fertility enhancement occurs on a continuum from trying to optimize the conditions to achieve pregnancy to a desperate attempt to achieve and maintain pregnancy when all other options are failing. It is this continuum that needs to be more fully understood, and which is likely to provide patterns of CAM use not seen in the general literature.

The diversity of modalities and practices reported in the studies reviewed point to the fact there is no clear or common definition of CAM. This raises the question of what should be included as CAM in reproductive health research to further our knowledge in this area. Should a definition of CAM in reproductive health research be limited to the ingestion of biologic substances or the use of modalities that can potentially harm women or their fetuses and for which a strong evidence base is needed? Accepting a wider definition, which includes all practices and modalities irrespective of potential harm, could serve different research purposes, such as developing an understanding of women's desperation to achieve parenthood or the impact of relaxation, reassurance, and attention on achieving and maintaining a pregnancy.

Conclusions

The field of fertility enhancement with the use of CAM is a rapidly growing one, and this article is an important first step because it highlights the gaps in our knowledge. Understanding the characteristics of users of CAM for fertility enhancement, their motivations, factors impacting on their choices, and the information sources contributing to decision-making is therefore important. There is an urgent need for a research agenda that includes broader sampling, strict definitions of CAM, and greater consistency across studies, in order to rigorously develop knowledge that can inform women, CAM and medical practitioners, and policy decision-makers alike. In the first instance, there is a need for well-designed national population-based studies that can answer the questions that are raised in the literature reviewed in this article. Such studies will make important contributions to the growing body of information about the benefits, harms, and costs of using different CAM interventions for fertility enhancement, as well as the resource implications of this use.

Footnotes

Disclosure Statement

No competing financial interests exist.

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