January 18th, 2019

Volume 54
July 2009
Number 7
Use of Nonmedical Treatments by Infertility Patients
     
Jonathan Schaffir, M.D., Alana McGee, B.S., and Elizabeth Kennard, M.D.

 

OBJECTIVE: To discover the extent to which infertility patients use alternatives to traditional medical treatment and to identify factors that may promote patients to use them.
STUDY DESIGN: Women seeking treatment for infertility at a private office in the Midwest were offered a questionnaire inquiring about their use of nonmedical therapies. Participants were asked about demographic information, types of medical and nonmedical treatments used and the reasons for using them.
RESULTS: Of 133 patients who completed questionnaires, 88 (62.2%) indicated use of alternative therapies. The most common were religious intervention (33.8%), changes in sexual practices (28.6%) and dietary changes (21.8%). Patients using alternative therapies were significantly younger than those who did not (33.2 vs. 35.6, p<0.01), but there were no significant differences between the groups in education, parity or length of infertility. The most common reasons given for using alternative methods were “No harm in trying” (56.8%) and “To supplement traditional therapies” (46%).
CONCLUSION: Alternative or complementary methods are used by a majority of infertility patients, particularly those who are younger. Patients indicate that such methods complement rather than compete with traditional medical methods. (J Reprod Med 2009;54:415–420)

Keywords: complementary and alternative medicine, folklore, infertility, survey.
     

  The study showed no difference
in use of such interventions by
women of different income,
education, length of infertility
or parity.


For as long as there have been couples trying to conceive, there have been various rituals, fertility aids and recommendations to improve chances of conception.1 With the development of the Internet, such recommendations have become increasingly widespread, with so-called “expert” advice available at the touch of a button. Some of the recommendations that are circulated may seem silly or innocuous, such as those advising women to adopt different sexual positions, change the undergarments of the male partner, or adopt superstitions such as rubbing the abdomen of a pregnant woman.2 Other recommendations may involve an indeterminate amount of risk (e.g., with the ingestion of herbal remedies) or cost (e.g., with the adoption of services such as acupuncture or yoga instruction) without proven benefit.3 
    Although examples of nonmedical conception advice abound on the Internet, in lay magazines and in waiting room conversations, it remains unclear to what extent such advice is followed. Although sociologic literature exists to document folkloric beliefs in non-Western cultures, there is scant research to describe its popularity in contemporary American society. A 1992 survey of 351 Dutch infertility patients revealed that 12% chose to include “alternative medicine” in their treatment, but did not specify what types.4 In the only study to examine this question in the United States,5 46 infertility patients responded to a survey, indicating that 91% of them had incorporated some alternative treatment into their care, including vitamins, herbs, mind-body techniques and exercise. Although this study suggested that such treatments are highly prevalent, it was a small sample of well-educated patients in an urban setting.
    The current study was designed to discover the extent to which such recommendations are followed in a Midwestern suburban community. The objective was to find out which alternative and nonmedical treatments are being used by couples seeking traditional medical infertility treatment, and also to determine whether there are specific demographic factors or reasons that determine whether such advice is followed.
   
Materials and Methods
Data were gathered from patients seeking treatment for infertility at a Midwestern suburban office. Anonymous, voluntary questionnaires were made available in the waiting room, with a cover sheet explaining that the study sought to find out about treatments being used other than the ones recommended in this office. Respondents were instructed to deposit completed surveys in a secure container. Subjects were polled on demographic information that was suspected to influence their cultural beliefs, including age, years of education, income level, race/ethnicity and nationality. They were also asked to identify the medical treatments they had already used, namely ovulation induction, donor insemination, intrauterine insemination, tubal surgery, in vitro fertilization (IVF) and ovum donation.
    Respondents were then asked to choose from a list of potential alternative therapies they had used and were asked where they had received each specific recommendation. They were specifically asked to mark only those therapies they had used expressly for the purpose of getting pregnant. The treatments listed were those that the authors had encountered in practice and reading of lay media, specifically acupuncture, herbal remedies, relaxation techniques, dietary changes, changes in sexual practices, religious intervention and use of fertility accessories. The survey also asked patients to specify exactly what type of treatment was pursued in each case. Finally, they were asked to choose from a list of potential motivations for using alternative treatments. The possible reasons were culled from the authors’ experience, and also from those responses provided in the study by Galst.5 
    Questionnaires were collected over a period of 6 months. Because the study was descriptive by nature, no power analysis was performed in advance. Demographic information was compared between those using alternative treatments and nonusers with t tests for numerical data and contingency tables for categorical data. This study was determined to be exempt from review by the institutional review board at The Ohio State University.
   
Results
A total of 133 completed surveys were collected during the study period, during which time 1,063 patients were seen in the office for infertility, yielding a 12.5% response rate. Demographics of this group are shown in Table I. The population at this office was predominantly White, with a small number of minorities. Although subjects were also asked to identify nationality in order to get a sense of cultural differences, there were few who identified as other than American, and a large number either declined to answer or misinterpreted this question as “heritage.” Of those who responded in such a manner, various European heritages were identified.
   

   
    Eighty-eight patients (66%) stated that they used 1 of the alternative therapies listed. Table II displays the percentages using each intervention. The most common alternative to standard medical therapy was religious intervention, including both prayer and intercession (having others pray on one’s behalf). The next most common intervention involved changes in sexual practice. Although some patients interpreted this response as involving position changes or postcoital adaptation (e.g., resting with legs elevated, remaining supine), 21 of the 38 respondents stated only that they were told to have sex more frequently or on fertile days, which would not necessarily be an “alternative” to standard practice.
   

   
    Dietary changes listed included a variety of adaptations, including both high- and low-fat diets, decreased carbohydrate intake and caffeine restriction. Foods identified as enhancing fertility were soy products, yams and walnuts. Of the 29 responses in this category, 12 identified only vitamin supplementation, which may reflect confusion between infertility treatment and prevention of congenital defects.
    Most respondents who admitted to use of an alternative treatment listed more than 1 method. There were only 9 who described their treatment as limited to only supplemental vitamin use or more frequent intercourse. Even if these “mainstream” responses are eliminated, the prevalence of alternative treatments is still 59.4%.
    The majority of patients using relaxation techniques identified yoga or massage as fertility aids. Of those respondents using herbal therapies, half cited supplements containing chasteberry (Vitex agnus castus); others identified soy, evening primrose, yam extract and raspberry tea as helpful. All of the responses regarding change in attire involved the male partner’s use of boxers instead of briefs. Few patients subscribed to the use of fertility accessories, but these included charms, a prayer card, Kokopeli pictures and a rooster figurine.
    The demographics of patients who used alternative treatments were compared with those of nonusers, as shown in Table III. Women who tried an alternative treatment were younger than those who did not. There was no difference between the groups in education, income, gravidity, parity or years of infertility. Because of the small number of women who were non-White and non-American, conclusions regarding differences in ethnicity and nationality could not be made. The experience of in vitro fertilization was used as a marker of in-depth involvement with medical therapy. There was no difference in the percent of patients who had undergone this experience.
   

   
    Table IV summarizes the reasons patients gave for turning to nonmedical treatments for infertility. The most common reason was that patients saw no harm in trying alternatives (36.8%). The next most common reasons were “supplementing traditional medical treatment” (27%) and “to try everything/ out of desperation” (24.1%). Very few identified dissatisfaction with conventional medicine (3.4%).
   

   
    Responses related to the source of various recommendations were often missing. Of those sources cited, the most common were family members and friends, followed by the Internet, medical personnel and other media. The Internet was most frequently cited as a source of information about herbal or nutritional supplements, change in attire and change in sexual practice. Those therapies that had been recommended by physicians most commonly were having sex on fertile days, having men wear boxers, taking vitamins and relaxation such as yoga and exercise.
   
Discussion
This study demonstrates that many infertility patients are using therapies and interventions in addition to those routinely used in medical practice. Advice on incorporating such therapies comes from a variety of sources; some, such as the Internet, may disseminate advice not easily obtained in the past, but for most the recommendations came as they have for centuries—from peers and family.
    The study showed no difference in use of such interventions by women of different income, education, length of infertility or parity. One might think that women of a higher socioeconomic status would have more resources to use other therapies, or that women struggling with infertility for a longer time might turn to other therapies out of a greater sense of frustration. Our data suggest, however, that most women are equally exposed to such recommendations and these factors do not affect their choices. We did see a tendency for younger women to be more likely to incorporate alternative therapies. This may be due to a greater open-mindedness to alternative approaches in youth, or to a greater likelihood of responding to advice given by those who are perceived to wield authority. Given that infertility rituals are described more in less developed cultures, cultural and national influences are likely to affect the use of nonmedical treatments as well. Unfortunately, our study population was too homogeneous to examine this hypothesis.
    The nonmedical therapies identified by this population are prevalent in this community, and may not be generalized to other cultures and time periods. Still, many of these recommendations have existed for generations, and the fact that they are still in use suggests that some must be useful or effective. Very few, however, have actually been studied for evidence of their efficacy.
    Changes in diet are one intervention that has received scientific scrutiny. Previous studies have established that attention to a weight loss diet and exercise improves ovulatory function and fertility rates in women with polycystic ovarian syndrome.6 More recently, researchers examined the diets of healthy women trying to conceive and found higher conception rates among those who adhered more closely to a “fertility diet” consisting of fewer trans fats, fewer animal proteins, low-glycemic carbohydrates, high-fat dairy and multivitamins.7 There is no evidence that an individual woman with unexplained infertility will conceive more readily by following a particular diet. However, it is possible that women with infertility related to ovulatory disorders may benefit from modification of diet and lifestyle.
    Acupuncture has also received attention recently in the scientific press. Although many continue to express skepticism,8 a recent meta-analysis has demonstrated improved rates of pregnancy among women who use acupuncture as an adjunct to in vitro fertilization.9 Its benefit for spontaneous conception is more questionable. A review of studies examining the use of acupuncture in both male and female subfertile patients finds the evidence unconvincing.10
    Few herbal supplements have been subjected to adequate study regarding efficacy. Many commercially available products contain blends of multiple ingredients, making it difficult to know which if any are beneficial. We found chasteberry to be the most frequently recommended herbal supplement, and it is available in several products available over the counter. One such product, FertilityBlend (Daily Wellness Co., Honolulu, Hawaii), was examined in a placebo-controlled, double-blinded study of 93 women and shown to improve conception rates in only 3 months.11 A review of literature on chasteberry, however, does not find adequate support for its use in infertility.12 Moreover, although it is believed to be generally safe, it can cause adverse effects such as headache, rash and gastrointestinal disturbance.13
    The belief that less restrictive male undergarments will contribute to fertility is widely touted by both medical personnel and lay media. Some studies have demonstrated that scrotal cooling, whether by an air stream14 or by a “scrotal douche,”15 can increase sperm counts in subfertile males. However, in the only study specifically addressing the issue of male undergarments, there was no improvement in men who changed from briefs to boxers.16 
    Other techniques included in this study have never been shown to directly affect fertility, but may indirectly contribute to medical treatment in a positive way. The diagnosis of infertility and its subsequent treatment are associated with feelings of frustration, anxiety and stress. Religious beliefs may contribute to a sense of hope and allow patients to cope with the stress of infertility treatment.17 Treatments that are focused on relaxation techniques, such as yoga or massage, may contribute to a general sense of well-being and even improve the doctor-patient relationship.18
    For other folkloric interventions, no data exist. The notion that increasing the amount or duration of seminal fluid’s contact with the cervix will make conception more likely has led to recommendations regarding changing the coital act. Such changes, such as keeping the woman on the bottom, elevating the legs or hips, or remaining supine after intercourse, have never been studied in a scientific manner. Fertility accessories such as charms and statuettes date back to prehistoric times and are recognized in a variety of cultures,19 but will never be studied and are generally only of historic interest.
    There are several issues that limit the conclusions drawn from our study. Because the survey was self-administered, there was no opportunity to directly explain the questions asked. Although the intent of the study was to identify only those practices that lie outside of mainstream medical therapy for infertility, many responses included interventions that are not “nonmedical.” For example, a large number of patients misinterpreted the phrase “change in sexual practices” to include changes in frequency of sexual activity around the time of ovulation. Also, many of the interventions cited, such as prayer or use of boxer shorts, might not be considered alternative treatments because they are so widely practiced already in the community. A more stringent definition of “alternative” treatments would yield a significantly lower prevalence of use.
    The scope of questions asked was limiting as well. The questionnaire was necessarily kept brief to encourage subjects to participate. No responses were elicited involving specific infertility diagnoses, input from partners or additional cultural influences. There was no way to tell if the questionnaire was filled out alone or in consultation with a partner present. The misinterpretation of the term “nationality,” which some subjects took to mean heritage or ethnicity, made it impossible to draw conclusions about the effects of cultural background. In the future, a direct interview approach could yield additional information that would clarify the prevalence of and factors contributing to the use of alternative treatments.
    The survey methodology also carries an inherent selection bias. A relatively small fraction of patients in this office chose to complete the survey. Patients who have an interest in complementary and alternative therapies might have been more likely to take the time to complete the questionnaire. On the other hand, women who incorporate practices that might be perceived as odd or outlandish might be reluctant to share their experiences, even if the survey is anonymous. Administering a survey tool during a face-to-face encounter would yield a more accurate measurement of the nature and scope of alternative treatments being used.
    For the most part, the adjunctive treatments in this study were mild and innocuous. Although most are of little proven benefit, they may contribute positively to a patient’s experience of infertility treatment either by giving a sense of empowerment or control or by helping to relieve some of the stress of this process. Some interventions may involve substantial monetary cost, such as acupuncture or relaxation techniques, with benefit that may not justify such an outlay. Some herbal preparations may even have an ill effect on health and well-being. Physicians providing care for infertile couples may therefore want to inquire about such practices and be able to counsel their patients accordingly.
    
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From the Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, The Ohio State University College of Medicine, Columbus, Ohio.

Presented in poster form at the 63rd Annual Meeting of the American Society for Reproductive Medicine, Washington, DC, October 15–17, 2007.

Address correspondence to: Jonathan Schaffir, M.D., 2831 Cramblett Hall, 456 West 10th Avenue, Columbus, OH 43210 (Schaffir.1@osu.edu).

Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.




  
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