Evaluation of the use of alternative and complementary therapies and conception status of women receiving infertility treatment

Abstract

This study aims to evaluate the use of alternative and complementary therapies and conception status of women receiving infertility treatment. A total of 349 patients who applied to the infertility department of Medipol University and Private Nisa Hospital between October 1st and November 30th, 2020 were included in the study on their consent in participating in the research. Data was collected through face-to-face interviews using an information form prepared in accordance with the literature review carried out by the researchers. The pregnancy status of the patients was recorded as a result of the treatment and their relationship with the use of alternative and complementary therapies was examined. Of the 349 patients who participated in the study. A statistically significant difference (p [Med-Science 2021; 10(2.000): 564-70]

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ORIGINAL ARTICLE
Medicine Science 2021;10(2):564-70
Evaluation of the use of alternative and complementary
therapies and conception status of women receiving infertility treatment
Asiye Uzun1, Guzin Zeren Ozturk2, Ayse Karahasanoglu1, Saliha Busra Aksu3, Beray Gelmez Tas4
1Department of Obstetrics and Gynecology Medipol Teaching and Research Hospital, Istanbul, Turkey
2Department of Family Medicine Şişli Etfal Training and Research Hospital, Istanbul, Turkey
3Aslanapa District State Hospital, Department of Family Medicine, Kutahya,Turkey
4Department of Family Medicine, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
Received 04 April 2021; Accepted 26 April 2021
Available online 06.05.2021 with doi: 10.5455/medscience.2021.04.112
Copyright@Author(s) - Available online at www.medicinescience.org
Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Abstract
This study aims to evaluate the use of alternative and complementary therapies and conception status of women receiving infertility treatment. A total of 349 patients
who applied to the infertility department of Medipol University and Private Nisa Hospital between October 1st and November 30th, 2020 were included in the study on
their consent in participating in the research. Data was collected through face-to-face interviews using an information form prepared in accordance with the literature
review carried out by the researchers. The pregnancy status of the patients was recorded as a result of the treatment and their relationship with the use of alternative and
complementary therapies was examined. Of the 349 patients who participated in the study. A statistically signicant dierence (p<0.001) was detected between using as-
sistive treatment methods and the length of infertility duration (year) and infertility treatment duration (month). Furthermore, the dierence between using complementary
therapies and age (p=0.011), income status (p<0.001), marriage duration (p<0.001), infertility type (p=0.010), and the source of infertility (p=0.009) was also found to be
statistically signicant (p<0.001). 103 (%70.48) women were found to be pregnant after the infertility treatment. The most commonly used alternative and complemen-
tary therapy in pregnant women was visiting shrine (38.05%, n = 43), while the most used Traditional and Complementary Medicine method was cupping (37.50%, n
=27). 90 (87.37%) of the pregnant women used an complementery method and this was statistically signicant (p <0.001). However, there was no relationship between
acupuncture, cupping and conception (p: 0.997, p:0.090, respectively). We found a signicant relationship between the use of alternative and complementary therapy and
conception; and the most successful Traditional and Complementary Medicine method was cupping but no relationship was found between cupping and conception so
further studies needed to be done whether this method aects pregnancy.
Keywords: Infertility, complementary therapies, herbal medicine, acupuncture
Introduction
Infertility is a signicant health problem that aects not only
individuals but also communities [1]. It is a challenging process
that is dicult to handle especially for couples as it could cause
traumatic situations because of its psychosocial dimensions [2].
It is already a well-known fact that psychological factors play
a crucially important role together with physical disorders and
problems [3]. Infertility treatment processes could be highly
demanding and exhausting due to factors such as its high costs,
monthly treatment programs, and uncertainty of successful results
[4].
Moreover, applications during treatment causing extra burden
on especially women’s physical wellbeing aect their quality of
life negatively [5,6]. All these negative aspects cause people to
use alternative and complementary therapies (ACT) during this
demanding period.
In addition to traditional and complementary medicine (T&CM)
methods, religious actions such as praying or paying visits to
shrines – tombs of religiously important historical gures – are
also among alternative and complementary therapies used during
this process. T&CM is dened as all explained and unexplained
applications that are mainly based on various beliefs, traditions
or experiences, which are used not only to diagnose and treat
physical and psychological illnesses but also to maintain good
health. Methods such as acupuncture, cupping, and phytotherapy
are called as T&CM applications [7]. Approximately 30-60% of
Medicine Science
International
Medical Journal
*Coresponding Author: Saliha Busra Aksu, Department of Family Medicine
Şişli Etfal Training and Research Hospital, Istanbul ,Turkey,
E-mail: drberaygelmez@hotmail.com

565
infertile couples have been found to use complementary therapies
to increase their chance of success [8].
This study aims to evaluate the use of alternative and complementary
therapies and conception status of women receiving infertility
treatment.
Material and Methods
A total of 349 patients who attended to the infertility department
of Medipol University and Private Nisa Hospital between October
1st and November 30th, 2020 were included in the study on their
consent in participating in the research. The sample size of the
study was calculated to be 349 subjects with 98% reliability
taking 3800 as the average number of patients coming to the
department in 2 months considering the yearly total number of
applications to the department in one year. In collecting data,
face-to-face interviews were used with an information form
prepared in accordance with the literature review carried out
by the researchers were used. In the rst part of the form used,
sociodemographic status of the subjects was investigated while in
the second part, infertility and treatment histories together with the
use of complementary therapies of participants were focused on.
The ethical committee approval to carry out the study was granted
with a written permission authorized by the decision number 840
dated November 12th, 2020 by Istanbul Medipol University Non-
interventional Research Ethics Committee.
All the statistical analyses were performed using SPSS software
version 25.0. Continuous variables were presented on the tables
as mean, whereas categorical variables were reported as numbers
and percentages. Comparisons between groups were made using
Mann-Whitney U Test for continuous variables and Fischer Exact
Test for categorical variables. p<0.05 was accepted as statistically
signicant.
Results
As shown with the sociodemographic data illustrated on Table 1,
of the 349 women who participated in the study, 51.57% (n=180)
were at the ages of 25-34 while 57.60% (n=201) of the husbands of
the subjects were at the age of 35 and over. In terms of education
levels of the subjects, the biggest group was high school and
university graduates with 46.42% (n=162). The biggest group
in terms of education levels of husbands was high school and
university graduates with 58.18% (n=203).
Table 2 illustrates the evaluation of the infertility and treatment
histories of the women who participated in the study. Of the
couples who participated in the study, 51.86% (n=181) were
primary infertile, and 47.85% (n=168) were identied to be
in the secondary infertile group. Analyzing the etiology of the
infertility of participants, it was found that 33.68% (n=135) of
them were female fertility, 18.63% (n=65) were male fertility,
28.94% (n=101) were both female and male fertility, and 13.75%
(n=48) were unexplained infertility – infertility whose causes are
not known. The average length of infertility period of the female
participants was 4.21 (year), and their average length of treatment
was 21.16 (month).
Table 1. Sociodemographic characteristics of the participants
Variables n (%)
Age
15-24
25-34
35 and over
32 (9.18)
180 (51.57)
137 (39.25)
Husband’s Age
15-24
25-34
35 and over
15 (4.29)
133 (38.11)
201 (57.60)
Education Level
Illiterate
Below high school
High school and over
26 (7.45)
161 (46.13)
162 (46.42)
Education Level of Husband
Illiterate
Below high school
High school and over
10 (2.86)
136 (38.96)
203 (58.18)
Employment Status
Employed
Unemployed
167 (47.85)
182 (52.15)
Income Level
<2000 TL
2000-5000 TL
>5000 TL
27 (7.47)
257 (73. 85)
65 (18.68)
Duration of Marriage
1-5 year
6-11 year
12 year and over
116 (33.24)
181 (51.86)
52 (14.89)
TL: Turkish Lira
Table 2. The evaluation of infertility and treatment histories of the participants
Variables N(%) or Mean ± SD
Type of Infertility
Primary Infertility
Secondary Infertility
181 (51.86)
168 (47.85)
Cause of Infertility
Female Infertility
Male Infertility
Both Female and Male Infertility
Unexplained Infertility
135 (38.68)
65 (18.63)
101 (28.94)
48 (13.75)
Infertility Period (year) 4.21±3.84
Infertility Treatment Period (month) 21.16±29.04
SD: standard deviation
The use of ACT methods by the participants and its causes are
evaluated on Table-3, and it has been found that 66.47% (n=232)
of them reported using at least one ACT. When those who didn’t
use any ACT before were asked about the reasons why they didn’t,
59.3% (n=206) reported that they didn’t believe it to be helpful.
On the other hand, 40.68% (n=143) of those who used at least
one ACT said that they used it just because they believed it to
be eective. The source of information about ACT was reported
respectively to be 40.97% from relatives, 23.49% from media,
22.92% from internet, and 22.92% from medical personnel.
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566
Table 3. Other dening variables about patients
Variables N (%)
No Yes
Reasons for Using T&CM
Believe it to be helpful 206 (59.03) 143 (40.68)
To increase the number of sperms 284 (81.37) 65 (18.05)
Believe it to reduce stress 287 (82.23) 62 (17.76)
To heal yourself 333 (82.23) 16 (17.76)
To increase the chance of success 270 (77.36) 79 (22.64)
Information Source about T&CM
Relatives 206 (59.03) 143 (40.97)
Media 267 (76.51) 82 (23.49)
Internet 269 (77.08) 80 (22.92)
Health Employee 336 (96.27) 13 (3.73)
Reason for not using T&CM
I don’t believe it 294 (84.24) 55 (15.76)
I haven’t heard about it 273 (78.23) 76 (21.77)
I couldn’t nd time 273 (78.23) 76 (21.77)
Others 275 (78.79) 74 (21.21)
The ACT methods that the female participants knew and used are
demonstrated on (Table-1) and 2. As can be seen on these tables,
the most well-known ACT is shrine visits by 59.8% (n=209) while
the most well-known T&CM application is cupping by 46.42%
(n=162). It has been observed that the most preferred ACT is
consulting with a hodja – a religious character generally thought
to have healing powers using religious methods – by 41.84%
(n=146), followed by visiting a shrine with 32,66% (n=114) of the
participants. The most commonly used T&CM method is cupping
with 46.42% (n=162) of the participants reporting to have used it
at least once. When the practitioner of ACT was asked, 57.45%
(n=135) of the participants reported religious people, 15.32%
(n=36) certied practitioner, 13.62% (n=32) health professionals,
and 13.62% (n=32) people with no specic expertise.
76.79% (n=268) of the participants expressed use of vitamin and
mineral supplements. When their herbal remedy applications were
asked, 53.01% of them reported using onion cures, 26.94% carob
molasse, 26.36% consuming honey (Figure-3).
Figure 1.The ACT methods known by the participants
Figure 2. The ACT methods used by the participants
Figure 3. Herbal applications used by the participants
Evaluation of the factors that aect the use of ACT is illustrated on
Table 4 and Table 5. A statistically signicant relation was found
between the use of ACT and age (p=0.011), income (p<0.001), the
length of marriage (p<0.001), infertility type (p=0.010), and cause
of infertility (p=0.009). It was found that ACT use was much more
common especially among those who were secondary infertile and
particularly in the group of female related infertility, who were at
the age of 35 and over, with middle income levels, and married
for 6-11 years. Furthermore, the relation between ACT use and the
length of the periods of infertility (year) (p<0.001) and infertility
treatment (month) (p<0.001) was found to be statistically
signicant. It was recognized that ACT use was more common
among those with longer periods of infertility and infertility
treatment (Table 5).
103 (%70.48) women were found to be pregnant after the infertility
treatment. The most commonly used alternative and complementary
therapy in pregnant women was visiting shrine (38.05%, n = 43),
while the most used Traditional and Complementary Medicine
method was cupping (37.50%, n = 27). 90 (87.37%) of the
pregnant women used an adjunct method and this was statistically
signicant (p <0.001). 72 (69.9%) of those who got pregnant tried
consulting to a hodja, 43 (41.7%) tried visiting shrine; 27 (26.2%)
tried cupping; 13 (12.6%) tried amulets; 10 (9.8%) tried going
on pilgrimage; 8 (7.8%) tried abdomen pulling, 8 (7.8%) tried
acupuncture; 6 (5.8%) tried sacricing an animal; 1 (1%) tried
putting milk into the uterus, 1 (1%) tried putting meat into the
uterus, and 1 (1%) tried homeopathy. 90 (87.37%) of the pregnant
women used an complementery method and this was statistically
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567
signicant (p <0.001). However, there was no relationship
between acupuncture, cupping and conception (p: 0.997, p:0.090,
respectively).
The most preferred food-based methods of the pregnant women
were onion cure 27.32% (n = 50), mesir paste 37.32% (n = 25) and
honey 33.69% (n = 31). The most preferred food-based methods
of non-pregnant women were onion cure 72.68% (n = 133), mesir
paste 62.68% (n = 42) and honey 66.31% (n = 61). There was no
signicant relationship between conception and onion cure, mesir
paste and honey (p = 0.346; 0.119; 0.305, respectively).
Table 4. The evaluation of the factors aecting ACT use
Using ACT N (%) P
Yes No
Age*
15-24 15 (46.87) 17(53.13)
0.011*25-34 116 (64.44) 64 (35.56)
35 and over 101 (73.72) 36 (26.28)
Husband’s Age*
15-24 7 (46.66) 8 (53.34)
0.20825-34 87 (65.42) 46 (34.58)
35 and over 138 (68.66) 63 (31.34)
Education Level*
Illiterate 18 (69.23) 8 (30.77)
0.085Below high school 116 (72.05) 45 (27.95)
High school and over 98 (60.49) 64 (39.51)
Education Level of Husband*
Illiterate 6 (60.00) 4 (40.00)
0.134Below high school 99 (72.94) 37 (27.21)
High school and over 127 (62.56) 76 (37.44)
Employment Status*
Employed 111 (66.47) 56 (33.53) 0.997
Unemployed 121 (66.48) 61 (33.52)
Income Level*
<2000 TL 13 (50.00) 13 (50.00)
<0.0012000-5000 TL 191 (74.32) 66 (25.68)
>5000 TL 29 (43.07) 37 (56.93)
Duration of Marriage*
1-5 year 52 (44.83) 64 (55.17)
<0.0016-11 year 142 (78.45) 39 (21.55)
12 and over 38 (73.07) 14 (26.93)
Infertility Type*
Primary Infertility 109 (60.22) 72 (39.78) 0.010
Secondary Infertility 123 (73.22) 45 (26.78)
Cause of Infertility*
Female Infertility 97 (71.85) 38 (28.15)
0.009
Male Infertility 46 (70.77) 19 (29.23)
Both Male and Female Infer-
tility 67 (66.34) 34 (33.66)
Unexplained Infertility 22 (45.83) 26 (54.16)
Pregnancy*
Yes 90 (87.37) 13 (12.63)
No 142 (57.72) 104 (42.28)
*Chi-square Test
Table 5. The comparison of ACT use and duration of infertility
Variables Using ACT
NUsing
(Mean ± SD) NNot Using
(Mean ± SD) p
Infertility period (year)* 232 4.85±4.21 117 2.94±1.73 <0.001
Infertility Treatment
Period (month)* 232 25.68±33.13 117 12.21±14.95 <0.001
*Mann Whitney U test
Discussion
Infertility, with its already increasing prevalence, is a signicant
biological and sociological phenomenon that aects 10-15% of
the couples at age of reproduction, and when considered in terms
of etiological perspectives, the problem could be, on average,
resulted from 40% male infertility and 40% female infertility
[9]. This gure’s being 33.68% (n=135) in our study could have
something to with the fact that the participants were chosen from
the women who applied to infertility department.
The desire to have children is considered to be crucial in terms of
both instinctive and cultural aspects, and if not fullled, it might
cause traumatic situations where people seek for various cures
[10]. As a result of the expectations from their community and
the feeling of failure resulted from these expectations, infertile
couples nd themselves in chaotic situation that negatively aects
their relations in marriage, sexual lives, future plans, self-respect,
and quality of life [11]. When surgical operations for diagnosis
and treatment are added to this already stressful psychological
period, couples could experience emotional traumas accompanied
by emotional outbreaks. Thus, couples experiencing this traumatic
period end up with ghting in a psychological battle against
themselves, which are resulted from anxiety, depression, fear, loss
of social status, isolation, fear of being labelled in society, guilt
feeling, and desperation [9,12].
Because of all these reasons, couples become more prone to search
for and use various other alternative ways to increase their fertility.
Although the use of ACT methods varies from one culture to
another, it is stated in scientic studies that it is between 21% and
91% [13]. In a study carried out in Turkey, this rate was found to
be 62% [8]. Our study has found it to be 66.47%, which is aligned
with the literature.
When asked, infertile couples reported using ACT methods that
they found more appropriate in terms of their cultural and religious
beliefs [14]. Analyzing the world literature in this area, it can be
observed that many women in Africa relate the cause of their
inability to have children with the jealousy of the people around
them and the voodoo made by their mother-in-law and consult
generally with traditional healers [14]. Women in South Africa use
herbal remedies grown in the area to increase their fertility or to
nd a cure for any problem related to their genital organ [15].
According to a study carried out by Papreen et al. in Bangladesh,
women prefer traditional medicine more than modern medicine as
they believe infertility problems are mostly caused by evil spirits
and supernatural powers [16]. In China, the most common method
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568
used for this kind of purposes is to pray gods. Moreover, praying
on the days between the 1st and 15th days of the heat period in
menstrual cycle is commonly believed to be more eective [17]. It
has been reported especially in Chinese medicine that some herbal
approaches such as Wenshen Yangxue, Antai Decoction, Xiaoyao
Powder considerably increase the chance of success [18].
It is a commonly expected and natural situation for individuals
to search for appropriate remedies and cures according to their
cultures and beliefs to get rid of infertility, since it is a long-lasting
and exhausting process [19].
As for Turkish culture, infertile women reported especially
using traditional methods, frequently visiting shrines, drinking
supposedly divine healing water, and relieving themselves praying
under old trees [20].
Another study carried out in this area has found out that religious
practices such as saying the most special prayers and Quran
verses or using special amulets prepared for this purpose are
more commonly preferred in order to increase the chance of
reproduction [21]. Similarly, our study found out that the most
commonly preferred ACT method was consulting with a hodja
with 41.84% of the participants reported doing so, followed by
32.66% visiting a shrine.
Acupuncture (60.4%) and massage (40.9%) are reported to be the
most frequently preferred T&CM methods according to another
study [22]. In our study, it was observed that the most common
T&CM method was cupping with 46.42% (n=162) participants
reporting to have used at least once, which is thought to have
resulted from cupping’s role in Muslim belief and individuals’
preference to use methods appropriate according to their religious
beliefs.
Özkan et al. have suggested that it has been found in their study on
the foods used for this purpose that the most famous applications
among women are onion (81.9%) and g (53.01%), and onion
cures (53.01%) [23]. In another study, among the women who
reported eating or drinking herbal mixtures, 37.9% preferred onion
cures/drinks, 17.1% carob molasses, 8.3% g cures/drinks, 7.1%
Alchemilla cures/drinks [24].
Another study has pointed out that among infertile couples,
especially males use such kind of dietary cures and they mostly
(82.9%) use honey and dried nuts for this purpose. (25) In our
study, the most common dietary cure was found to be onion cure
with 53.01% (n=185), followed by carob with 26.94% (n=94).
The most important factor that aects the use of such dietary
cures is patients’ belief that the chance of success and the strength
of their ovary will increase, and it has been observed that better
results were achieved when these methods were combined [25].
Those who are more interested in ACT methods have been found
to keep the treatment for longer periods compared to those who
are less interested, and it has also been found that those who
preferred ACT methods are generally people with lower level of
education and from rural areas [26,27]. Another study has pointed
out that those using supportive alternative methods together with
modern medicine are mostly people working at a profession with
a university degree, with a higher social status, and with a higher
income rate [28]. In our study, no relation between the use of ACT
methods and education level was observed; however, as the age
increased, a relation was found in the secondary infertility and
female infertility among those with middle income and married
for 6-11 years. Moreover, infertility period (year) and infertility
treatment period (month) were found to be longer among those
using ACT methods compared to those not using them. Similarly,
in one of the studies, it has been indicated that the patients whose
infertility treatment lasted longer than one year searched for
ACT methods more often, and they expressed the length of the
treatment period as their reason for searching alternative ways
[29]. However, patients generally hide this search from their
doctors following their treatment and report negative reactions,
criticism, the concern of not being supported as their reasons for
hiding it [30]. Likewise, the source of information regarding ACT
methods are mostly reported to be internet, television, magazines,
individuals with similar histories rather than health ocials
[31]. In our study, it was observed that the source of information
the participants had reported using were respectively relatives
(40.97%), media (23.49%), and internet (22.92%).
A signicant relationship was found between the use of ACT and
conception. In a study conducted with 1231 IVF patients in China,
it was reported that transfer success and the number of live births
increased in patients using ACT [32]. In our study, cupping was
the most commonly used T&CM method in pregnant women, but
there was no signicant correlation with cupping and conception.
In some studies, it has been observed that cupping has a positive
eect on pregnancy outcomes [33,34]. The prevailing opinion is
that acupuncture aects female fertility and promotes implantation
with a general sympathoinhibitory eect through increased blood
ow to the uterus and ovaries [35]. It also has positive eects on
the luteal phase [36]. It has been shown that acupuncture on the
day of embryo transfer increases pregnancy rates in women who
have undergone IVF [37,38]. In our study, no relationship was
found between acupuncture and cupping and conception. This may
be because the methods have been evaluated regardless of the way
in which they are applied, their number or the practitioner.
ACT could support the treatment as long as it is practiced by the
right person in the right way, but as can be understood from our
study, practices performed by those who have no professional
background in the relevant eld poses great risk. As ACT is
believed to be harmless and so the practitioner is thought to play no
important role, neither professional experience of the practitioners
nor their certications are generally investigated by patients.
However, ACTs, especially T&CM methods, should be performed
by certied health professionals. Furthermore, due to the common
use of these applications, we believe possible risks could only be
eliminated if doctors question their patients about the use of these
practices and warn them properly about the health risks that might
be resulted from inappropriate practices.
ACTs are commonly used in infertility treatments. In this study,
a relation was detected between the use of ACT methods and
secondary and female infertility of patients from middle income
group who have 6–11 year marriages, and it has also been found
that as the age, the period of infertility and infertility treatment
increase, the use of ACT increase, as well.
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569
Furthermore, it has been found out that the most common ACT is
prayers while the most prevalent T&CM method is cupping, and
the information about these practices has been found to be mostly
from relatives. These practices have been reported to be carried out
by individuals who have no professional expertise or certication.
We believe that possible risks and damages could be handed by
investigating about the use of ACT among infertile couples and by
guiding them properly.
Conclusions
We found a signcant relationship between the use of alternative
and complementary therapy and conception; and the most
successful Traditional and Complementary Medicine method
was cupping but no relationship was found between cupping
and conception so further studies needed to be done whether this
method aects pregnancy.
Conict of interests
The authors have no conicts of interest to disclose.
Financial Disclosure
All authors declare no nancial support.
Ethical approval
The ethical committee approval to carry out the study was granted with a written
permission authorized by the decision number 840 dated November 12th, 2020 by
Istanbul Medipol University Non-interventional Research Ethics Committee
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