Women’s Attempts Related to Complementary and Alternative Medicine Use in Infertility Causes and Diagnosis: A Narrative Inquiry

Abstract

In most cultures of the world, infertility is seen as a disaster and is associated with a myriad of emotional and psychological problems for women. Using Complementary and alternative medicine (CAM) can help treat infertility. The present qualitative study aimed to explore women’s attempts related to CAM use in infertility causes and diagnosis. This qualitative study has been carried out through a purposive sampling technique on 78 women living in Neyshabur, Iran. An individual interview and focus group discussions (FGDs) was used to collect data. Purposive sampling was used based on the objective of the study and the characteristics of a population. The data collection was discontinued when saturation occurred, and no new themes or information were explored in the data. Data analysis was performed by content analysis and Atlas T software. This study revealed medical diagnosis and traditional medicine, custom activity, medicine causes, and nutrition issues influence women’s view pints and attempt towards infertility and CAM use. Results suggested that infertility should be understood not only in biomedical terms but in light of cultural beliefs and the contingent need for culturally-appropriate supportive CAM. The application of CAM along with medical medicine is an essential element in assisting couples in infertility causes.

Keywords

complementary and alternative medicine infertility women qualitative study

Introduction

Infertility is a multifactorial and complex condition. Biological, infectious, genetic, environmental risk factors and lifestyle are associated with infertility.^1,2 Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse”.³ The researchers reported that in 2010, 10.5% of women (age 20–44 years) with a previous live birth were unable to have an additional live birth, and 1.9% of women who wanted to have children were unable to have their first live birth. A measured 48.5 million couples worldwide were unable to have their first live birth.^4,5

In Iran, more than 20% of couples deal with infertility during their reproductive age.⁶ The sexual, emotional, physical, financial, and spiritual aspects of one's life are all affected. The most common problem that reported is symptoms of depression, anxiety and dissatisfaction with life.⁷ The perception of people, women in particular, regarding childlessness is always remorseful and judgmental.⁸ As the primary agent of childbearing, women are the center of focus when infertility is diagnosed.⁹ It seems infertility is a highly gendered phenomenon and a woman as the first person is blamed if the couple ends to childlessness.¹⁰ Despite the fact that the cause of infertility is shared equally by the male (30% is male-factor) and women (female-factor) and 40% of cases are caused by a combination of male and female factors, some communities tend to attribute infertility exclusively related to women, even if they are not the cause of childbearing problem.^11,12 Therefore, it seems that misconceptions related to infertility and sexual relationship goals are influenced by culture, religion, and family, which can adversely affect the couple's relationship.^12,13 Under such pressure, people attempt to find any kind of therapy concordant with their financial and cultural status.¹²

In recent years, complementary and alternative medicine (CAM) is increasing for the treatment of infertility; known as the natural method with fewer side effects.¹⁴ Likewise, infertile couples may choose an alternative method because they may dissatisfy with the outcome of medical methods and its low costs.¹⁴ Hypnotherapy, acupuncture, osteopathic manipulation and chiropractic, naturopathy, traditional Chinese medicine, and homeopathy are common methods of CAM. Acupuncture and herbal supplements, used to supplement or replace assisted reproductive technologies, are the most studied infertility methods.^14,15 CAM use for infertility treatment has been investigated in studies from Canada, Australia, United States (US), United Kingdom (UK), Lebanon, Denmark, Jordan, Turkey, and Lebanon, reflecting women’ interest and acceptance in alternative methods for treatment of infertility.^14,16

Despite advances in assisted reproductive technologies in Iran, the use of complementary and alternative medicine (CAM) has shown an unprecedented increase.^17,18 There have been very few studies on the CAM’s effectiveness in Iran and the limited data available related to experience, attempt and behaviors of Iranian women toward nonconventional methods of infertility treatment and its causes and diagnosis process. A study ) investigated the attitude, knowledge, and practice of CAM in infertile patients and found that a considerable proportion of Iranian infertile patients have a positive attitude toward CAM and they use CAM without sufficient knowledge. They reported that 53.7% of infertile patients were not knowledgeable of CAM and 43.4% of patients had a positive attitude toward CAM. In this study, only 3.2% of infertile patients using CAM informed their physician.¹⁹ The findings of a study lend support to CAM’s efficacy in treating infertility. They examined the status of utilizing CAM in infertile couples in Iran and found that using CAM and promoting the knowledge of infertile patients is crucial.^5,20 The recent review study by Jang Won Lee et al. aimed to overview of the available studies on the outcomes of CAM for female infertility. This study confirms the overall quality and evidence of CAM’s effectiveness for female infertility. Conversely, some studies examined the link between CAM and outcomes of infertility found that CAM does not decrease the infertility rate.²¹

In Iran, there has also been a rise in the use of the traditional concepts and advise from the uneducated people who recommends methods to promote reproductive health to people. Most of these methods have been criticized for giving treatment that is not rooted in science.^5,22 This leads some couples believe that these methods and advice improve their infertility problem but may not actually work. This is a great area of concern for physicians and policymakers.⁵ Based on this literature alone, we cannot conclude the impact of CAM on infertility at this stage because the infertility problems and socio-demographic characteristics of CAM users leading to its consumption differ from country to country and geographically. The question is, are these types of treatments evidence-based, and why these alternative practices are being implemented more frequently is still unanswered. Therefore, more studies are needed in each country based on the context of anecdotes and rigorous empirical data to assess CAM’s effectiveness and impact of socio-demographic characteristics on the outcome of CAM for infertility problems. This presents impact of socio-demographic factors in each community that is driving people towards CAM methods.

In this respect, the present qualitative study aimed to investigate the experiences and attempts of women concerning the use of CAM for infertility problems in Iran. Likewise, we tried to identify the effective and hidden social factors associated with women’s behaviors toward a social understanding of CAM. Since, there is no database of CAM use for infertility causes in Iran, performing this type of study is crucial to gain a better understand of complex social phenomena and psychological processes and cultural contexts to promote women’s health and their quality of life.²³

Materials & Methods

Participants and Recruitment Strategies

This qualitative study has been carried out on 78 women living in Neyshabur. First, packs containing study information, contact details sheet and a screening questionnaire (family composition and socio-demographic background) were distributed to women attending in a larger study that evaluating women’s experiences of infertility treatment and CAM use from January 2017 to January 2020. Interested women completed the contact details sheet and screening questionnaire and returned it by mail to the research team. Purposive sampling was used based on the objective of the study and the characteristics of a population. This type of sampling was useful to ensure that the subsample of responding women reflected the diversity of the population. The focus was on women who had the potential to provide rich data and there was no age restriction for recruitment strategies. The inclusion criteria required that women were married, having children, lived in Neyshabur during the previous six months, have infertility experience and use of CAM for themselves or family members, and were willing to participate. The data collection was discontinued when saturation occurred, and no new themes or information were explored in the data. A recruiter explained the objective of the study for all eligible women and obtained written informed consent.

Data Collection

The aim was to use focus group interviews (FGDs) and semi-structured individual interviews, as they provide a forum for collective remembering as group members prompt each other, and allow exploration of the group dynamics of experience and views, and compare each other’s experiences and views. Data collection took place when the women who were attending a larger infertility study in Neyshabour agreed to participate in this qualitative study during Jun–August 2019. The FGDs and interviews were conducted in a health care center in Neyshabur. In some cases, such as the elderly participants, who were not patient enough to attend such group sessions, face-to-face individual interviews were conducted in their homes.

The interviews covered a flexible topic, such as the definition of infertility and CAM, the experience of consultations with CAM practitioners, traditional and clinical experience regard to infertility causes and diagnosis, and psychosocial factors influence infertility causes and diagnosis. women were asked initial main questions concerning infertility treatment (e.g., "How do people think of infertility treatment in your area?", "Why do you think infertility happens?" and "How do you think infertility is diagnosed?”) and then participants were encouraged to tell their narratives. Likewise, we asked additional question to understand more details about women’s idea and experience toward CAM use. Other questions were formulated based on issues raised in each meeting. The interviewer's team included experts in health education, midwifery, nursing and health workers and trained Health volunteers. Interviews were digitally recorded and transcribed by a professional transcriber. Interviews ranged in duration from 30 to 120 minutes.

Data Analysis

A qualitative content analysis was conducted based on the inductive approach where to categorize data. This process included coding, identifying and categorizing any patterns in the data. In fact, this analysis involves identifying most important and common themes/patterns, and the linkage between themes in the data. In this study, ATLAS.ti Software was used as tools to conduct thematic Content Analysis

The interweaving of data analysis and collection intend that understanding from earlier data analysis shaped later data collection, providing the interpolation of new concepts raised. In this study, interviews were handwritten according to the research question, and then the text was read several times to understand the content of the interviews and extract semantic units. The codes were then summarized and classified according to their similarity. The codes were subdivided into themes and then the main themes and meanings were extracted by examining the relevance of the themes.²⁴

In this study, the accuracy of qualitative findings was evaluated based on the criteria presented by Lincoln and Cuba, including credibility, conformability, dependability and transferability.²⁵ To do so, credibility data were presented to participants after each interview and further revisions and corrections were made based on their comments and feedback. To assess dependability, namely the fact that recorded experiences reflected the experiences of women participating in the study, and to continue the process of investigation, the findings of the study, including the main two external observers who examined themes and sub-themes, and necessary modifications were made. For to conformability the information, researchers attempted to set aside their views on topics of study as much as possible. Moreover, attempts transferability to similar situations the findings of this study also has a similar meaning to others.

Results

Subject demographic: Participants in this study included 78 married women aged 24-83 years old among four districts of Neyshabur city. The number of children ranged from 1 to 9 and their education ranged from illiterate to post-graduate (Table 1). The results of the study were considered for three topics: infertility diagnosis, causes of infertility, and women' view and experience toward CAM. According to this, 27 initial conceptual codes were obtained. The codes consisted of 11 sub-themes and 2 main themes (Table 2).

Table 1.

Demographic Variables of Women Participating in This Study.

Variable	Category	Number
Age	24–34	14
	35–44	12
	45–54	16
	55–64	14
	65–74	12
	>75	10
Number of children	0	3
	1–3	15
	4–5	24
	6–7	26
	8–9	10
Level of education	Illiterate	24
	Primary	22
	Cycle	20
	Diploma	12

Table 2.

Medical Perspectives Associated With Infertility Causes.

Sub-themes		Important comments from participants
Genital women infections	Menstruation infection	Fatima Sultan ^a45, 6, 3: “Menstruation infection caused by the use of the old cotton pads and wearing female underwear are also factors that affect infertility”.
	Wedding night	Banoo 75, 0, 8: “When a woman took a bath after losing virginity, she was recommended not to seat on the floor because the water could enter her uterus and causes infection”.
	After childbirth	Masoumeh 24, 12, 2: “A woman in labor should not drink water as it fills uterus with water and leads to infection and infertility”.
Ovarian cyst		Hadith 45, 9, 2: "Ovarian cyst is causes infertility".
Stress		Ezra 30, 9, 2: “Stress is causes of infertility”.
Heavy physical activity in men		Masoumeh 34, 9, 2: “frail men should not do heavy work as it weaken their semen”.
Female physical characteristics	Weight of women	Halimeh 31, 5, 2 ": over-weighted woman may not get pregnant because the extra fat postpones pregnancy".
Female physical characteristics	Age of women	Zakie 45, 9, 4: “prior to the pregnancy, age factor should be taken into account. The optimal age range of pregnancy was from 18 to 30 years when ovulation was perfectly healthy”.

^aAge, education level, number of children.

Infertility Diagnosis

Women believed in trying both medical diagnosis and traditional actions. Most of the Women participating in the study considered infertility as a major flaw and tended to use traditional methods to diagnose infertility. In this regard, the views and experiences of women on infertility have been examined.

Munira with 70 years old and seven children and illiterate about identifying the person infertile says: “to determine whether the man or woman is the cause of infertility, they both planted some pumpkin and barley seeds and then peed on it. It was believed that seeds urinated by the infertile person would not grow. However, if seeds still grew, the urination was repeated and this time infertility was determined based on the withering of buds”.

Bibi Fatima 34 years old with cycle education and two children states: “In the past, to determine female infertility, the woman was smoked by Gum of Nasturtium resin. If it induced urination, the women were considered as fertile and lack of any effect was seen as a sign of infertility”.

Maryam has two children and aged 33 years with primary education said: “Women who had late pregnancy or their menstruation was postponed for 2 or 3 months were believed to be infertile, and that they became pregnant once in every seven years”.

Causes of Infertility

Major themes extracted from narrations of the women for the question: “How do you think infertility is diagnosed and what are the causes?" were: a) Medical perspectives; b) traditional reasons and healing.

Medical Perspectives

Among participants, 11 believed that genital women infections were one of the factors affecting infertility, and observing hygiene during menstruation, at the time of losing virginity and in after childbirth period was pivotal to preventing female infection. They said that Stress and ovarian cysts are two causes of infertility. Participants believe that both men and women could be the cause of infertility. In men, heavy work was assumed to be the causes of sterility (Table 2).

Traditional Reasons and Healing

According to results, some participants (n=13) stressed the role of nutrition and diet in different periods such as menstruation, loss of virginity at the wedding night, sexual relationships, and post-delivery days in infertility. At the night of losing virginity and during menstruation, eating sour food such as sour apples, pickles and white pickle (eating vinegar and yogurt at the same time) and also drinking cold water, milk, coriander and melon were prohibited, as they were supposed to cool the uterus and result in infertility.

Among participants, 10 people regarded the use of contraceptives for example oral contraceptive pill or Natural methods a possible cause of infertility. It was said that contraceptives provoked back pain in women and contraceptives led to infertility, which explains reluctance tubectomy and vasectomy”.

Some other (n=3) believed that cleansing, showering, using pads and not wearing chador around the waist during menstruation led to infertility. One of the participants' superstitious beliefs about the cause of infertility is the fear of women and Chele. When you try to do something, but despite all of your efforts, there is always a problem that impedes or interrupts the completion of the task, it is said that thing has been Chele (doomed). Most of the participants claimed that Chele in women was the cause of infertility (n=19).

Another participant said that residual of menstrual blood or rupture of the hymen in the female reproductive tract could cause infertility. One of the participants stated that contact with domestic animals led to sterility. Also Of the religious beliefs was that in men, wearing gold was assumed to be causes of sterility. Finally, some respondents (n=4) posited that physical characteristics of a woman such as weight and age could affect her infertility (Table 3).

Table 3.

Traditional Reasons and Healing Associated With Infertility Causes.

Sub-themes		Important comments from participants
Nutrition of women	Menstruation infection	Bibi Ameneh ^a66, 0, 7: During menstruation, eating pickles and sour yogurt, sour apples and vinegar, and after childbirth, eating foods that are cold in nature may lead to infertility”
	Wedding night	Khadijeh 50, 5, 6: “At the wedding night and after losing virginity, women were discouraged from having pickles, cold water and white pickle as they were believed to be cold in nature and cause infertility.
	After sex	Zahra 70, 0, 5: “ A couple of participants (n= 2) said eating pickles by women after sexual intercourses cold reinforce the chance of.
	After childbirth	Sakineh 85, 0, 7: “women in labor had to refrain from eating meat as it made womb uterus barren.
Use of contraceptive methods	Oral contraceptive pill (OCP)	Bibi Sharifeh 80, 0, 6: “In the past, women did not believe in the use of pills and contraceptives, claiming that it was not befitting of girl to prevent pregnancy after her wedding, and newlyweds were advised to get pregnant in the first days and months of their marriage”.
Use of contraceptive methods	Natural methods of contraception	Fatima Sultan 45, 5, 3: “A couple who hinders natural fertility, will have to deal with infertility later”.
Superstitious beliefs		Bibi Ameneh 66, 0, 7: “In the past, women did not cleanse their body or take a bath as they assumed it could fill their womb with.
		Gol Pari 60, 0, 7: “if a woman was scared, she could not get pregnant unless she drank holy water.
		Farideh 26, 9, 2: “One of the causes of infertility is Chele falling on the woman in the sense that the person dies and is suddenly notified."
		Fatima 40, 0, 3: “for a newly married woman, if the blood oozed from hymen remains in her womb, it covers the ovaries and postpone the pregnancy".
Religious beliefs		Masoumeh 30, 14, 0: “Men should not use gold because it causes sterility."
Contact with pets		Fatima 30, 9, 2: “if a cat or dog’s hairs found their way into a female body, they could cause infertility. Therefore, close contact and touching of animals should be avoided".

^aAge, Education level, Number of children.

Women' View and Experience Toward CAM

Most of the women (75%) believed that medical treatment and advice from traditional practitioners are effective way to treat infertility and reduce treatment interactions. They indicated that most infertile women in their family and friends willing to use CAM methods. The most commonly used CAM methods are herbal medicines, acupuncture, prayer and vow.

Women expressed a range of different view and experience toward CAM use. Some participants (n= 28) indicated at their friends and family members who try anything to treat their infertility. They had intense hopes that CAM would influence their infertility problem and they were willing to tried any possible ways: ‘I did everything, everyone was telling me ‘maybe this will help, ‘I’ll try’, ‘I’ll do it’. Women who endorsed this view, mostly had been undergoing medical treatment of infertility for longtime and they experienced physical and emotional stress due to infertility treatment.

Most of women attitudes (n= 40) fell into casual optimism. These participants were not intensely trusted on CAM’s effectiveness and outcome. They believed that ‘‘they can’t hurt’’ or that ‘‘there is no harm in trying’’: these women were neutral in their viewpoint about CAM’s outcome, but believed that it would not harm in using CAM methods. Likewise, we found that the use of religious methods was more common among Iranian women. Most of women (n=58) believed that religious methods that intrinsically tied to their belief in the power of “God”, prayer and vow: ‘they think it’s like magic.’

Discussion

Although Assisted Reproductive Techniques (ARTs) tend to reassure communities about solving childlessness, there are still young couples who have difficulties to understand the medical reason for their infertility problems.²⁶ Several women's researches about infertility revealed that the diagnosis and causes of infertility is one of the main concerns in women population and little attention had been paid to the diagnosis of infertility. In this study we tried to explore women’s attempts related to CAM use in infertility causes and diagnosis. Our finding showed that most of the women believed that traditional methods with local and cultural origin influence infertility diagnosis. In this study we tried to explore women’s attempts related to CAM use in infertility causes and diagnosis. Some participants argued that one of the reasons for male infertility was heavy athletic activities, which have been proven scientifically. The study suggested that while short and intensive sessions of aerobic and anaerobic exercise led to increased serum levels of testosterone, heavy long-term exercises (more than 2 hours) could lead to an initial increase followed by a decline in serum testosterone level below the baseline. Other beliefs concerning the cause of infertility can also be scientifically explained. For example, in line with the beliefs of women in research, scientific studies have proven the impact of stress on female infertility.²⁷ According to recent researches, stress might influence the level of Estrogen and other endogenous hormones for example Luteinizing hormone, follicle-stimulating hormone (FSH), and progesterone.²⁸ Also, ovarian problems like ovarian cysts and infections were among the causes of infertility in women.

Another belief about the cause of infertility among women was neglecting hygiene during menstruation, which can increase the chance of genital infections such as vaginal bacteria and urinary tract infection.^4,22,29 Given that urinary tract infection is one of the leading causes of infertility, greater attention should be paid to this matter.³⁰ The results of a study in Pakistan showed that infertile women often used inappropriate material to absorb blood during their menstrual periods. Moreover, these women were more likely (4 times higher) to have a history of sexually transmitted infections.³¹ Further, the study of Das P, et al. Found that women who often utilized reusable pads to absorb blood during menstruation were more likely to get an infection than women who used disposable pads.²⁹ Therefore, it can be concluded that consistent with female beliefs in this study, failure to use sanitary pads during menstruation and infection can lead to infertility.

Other beliefs of the participants included the effect of age and female weight on fertility. Obesity has a negative influence on female fertility because it effects on ovulatory dysfunction due to dysregulation of the hypothalamic-pituitary-ovarian axis.³² Similar to the results of our study, in different studies, the negative effect of obesity on female fertility has been shown.^32–34 Further, results revealed that, contrary to the beliefs of the participants, there was no significant relationship between female Body Mass Index (BMI) and infertility.³⁵ Also Studies show that with age increases, the number of Leydig and Sertoli cells decreases, leading to a decrease in testosterone secretion and sperm quality. On the other hand, in women with increased age, there is a decrease in ovarian reserve and hormonal changes.³⁶

Also, consistent with the beliefs of our participants, Sumera et al. Stated that using contraceptive pills could lead to infertility.³⁷ However, scientific studies show that contraceptive pills can reduce the risk of primary infertility. This misconception can reduce the use of contraceptive methods and increase the rate of unwanted pregnancies, especially in developing countries and consequently leads to an increase in abortions.

One of the beliefs that demonstrated the influence of religion on people was the effect of wearing gold rings in men on sterility. Islam has forbidden the wearing of this metal for men, though there is not any scientific evidence to back it up. What is significant in this regard is the impact of religious convictions. In the same manner, the study of Sumera et al. showed that Pakistani women’s beliefs about infertility treatment were strongly influenced by religion and culture.³⁷

According to the results of the present study, one reason for infertility was inappropriate eating habits,³⁸ which in agreement with the study of Noventa et al. revealed that women with unknown cause of infertility were significantly more likely to have an improper eating habit in their diet.³⁸ Further, the study of Stewart suggested that certain dietary ingredients could harm fertility and reproductive health.^39,40 The results of another study also suggested that the use of meat, nuts, dried fruits and green vegetables in fertile women was significantly higher than infertile women.⁴¹ Nutritional factors for example saturated fat, red meat, processed meats, fatty dairy products, sugar and sweeteners, alcohol and caffeine may be responsible for infertility and increase the high consumption of soy and soy products may increase the risk of infertility in male.⁴² According to participants, a woman must pay greater attention to their diets, especially in certain periods, such as menstruation. Food customs are associated with the quality of life in women of the reproductive age. Food habits not only influence life style but also to induce disorders such as dysmenorrhea and irregular menstruation.⁴³

Toxoplasma contamination is one of the most common infections in humans and other warm-blooded animals that has a worldwide spread and is highly prevalent in Iran.⁴⁴ Infections with this immune cell in people with a healthy immune system usually have no clinical signs; however, infection of pregnant women with toxoplasmosis in some cases can lead to fetal death, preterm labor and congenital toxoplasmosis.⁴⁵

Unfortunately, superstitious beliefs were also rampant in the population of this study. One of the common superstitions was Chele and charm writing. The results of a study on Pakistanis indicated the strong belief of these people in evil forces and supernatural powers as the probable causes of infertility. However, infertility has medical cause.⁴⁶ As such, it can be stated that superstitions and deep-rooted customs are the main barrier to dealing with infertility problems. These belies can leave a detrimental effect on the control and treatment of infertility.

Conclusions

This study indicates that awareness and beliefs on infertility can overshadow the people’s health decision- making on infertility treatment that they originate in culture, religion and handed-down doctrines. There is a sustained tendency to use complementary and alternative medicine practices for infertility diagnosis because that is simple and accessible, and most are under the control of couples. Therefore, conditions should be provided for couples to use complementary and alternative medicine for infertility causes and educational intervention on how to use and result in this medicine.

Footnotes

Acknowledgements

The authors wish to express their gratitude towards the vice president of research in Mashhad University of Medical Sciences, the chiefs and staffs of the Health centers and the esteemed participants. Also, a deep gratitude goes to the participants for their contribution and all those who helped us during this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grants from the Mashhad University of Medical Science, Iran

Author Biographies

Mohsen Azimi-Nezhad is a MD, PhD in Health science, Nyshabur University Of Medical Sciences, Iran.

Malihe Noori Sistani is a graduate student in Master of health education and promotion in Mashhad university of medical science, Iran.

Mohammad Vahedian-Shahroodi is an associate professor of health education and promotion and a member of the department of health education and promotion, Faculty of health science, Mashhad University of medical science, Iran. His areas of interest in Public Health and Health education and intervention.

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