This study investigated the prevalence and determinants of CAM use among infertile patients attending the Assisted Reproductive Technology (ART) Unit at the American University of Beirut Medical Center, a major tertiary hospital in Beirut, Lebanon. We found that 41% of infertile patients used a form of CAM at least once as a treatment for their infertility. Studies on prevalence of CAM use among infertile patients reported a wide range of estimates. Similar to our findings, a study from the United Kingdom assessing CAM use among 400 infertile women found 40% of participants to have used CAM as a therapy for their failure to conceive [11]. Furthermore, in Denmark, a prospective observational cohort study reported a 31% prevalence of CAM use among infertile women [1]. However, in the United States, a lower prevalence was found in a cohort study of 428 couples seeking infertility treatment (29%) [10], while a relatively high prevalence (82%) of CAM use among Turkish infertile patients was recently reported [4]. Possible reasons for the discrepancy in prevalence estimates reported in the literature could be the heterogeneity of CAM practices, where there may be differences in what is defined as a CAM treatment and what types of CAM modalities are included in the studies. Other reasons may be differences in study design as well as in cultural backgrounds which could lead to differential patterns of use.
Our findings showed that among women, “spiritual healing”, specifically “prayer” and “religious vows”, were the most commonly practiced CAM therapies. Religious vows involve making a promise to perform a specific deed once the prayer has been answered. Lebanon seems to be a country whereby religion is highly influential on people’s daily practices, with prayer being an integral part of the culture. Spiritual healing has been suggested to have potentially beneficial effects through its provision of hope and in turn, a positive attitude towards patients’ conventional infertility treatment, as was suggested in the Turkish study assessing CAM use for infertility enhancement [4].
In this study, the most commonly utilized CAM therapy by men was “functional foods”, specifically fish, nuts, and seeds, honey and royal honey. Seeds and nuts have been reported by complementary medicine practitioners to be beneficial for treating infertility due to their polyunsaturated fatty acid content [18]. Honey has been traditionally used among the Lebanese and other Arab populations for treatment of many diseases, such as the common cold and cough, in addition to infertility. Royal honey, also called “food for queens”, is a honey bee secreted from the glands in the hypopharynx of worker bees that is believed to give the queen bees their longevity and fertility. Furthermore, honey is mentioned in both the Quran (the Muslim Holy Book) and the Holy Bible as having the feature of healing mankind [19, 20].
In addition to prayers and functional foods, our results showed that herbal therapies were used by men and women for infertility treatment, including blackseed, ginseng, maca, and marjoram. Blackseed, the common name for Nigella sativa L. seeds, is traditionally used as a spice and food preservative. Although hexane extracts of this seed have been shown to have significant antifertility activity in rats [21], it is a common belief among muslims and Christians in Lebanon and other countries of the Middle East that this seed possesses curative abilities for a wide range of diseases, including fertility [22]. Ginseng, maca and marjoram are herbal plants that have been suggested in the literature to confer beneficial effects on male fertility [23–25].
Although minimal or no risk has been associated with prayer and the use of functional foods for infertility treatment, herbal therapies have been reported to adversely affect chances of pregnancy and health. Phytoestrogens present in herbal supplements have been suggested to have negative estrogenic effects on implantation [1]. Furthermore, the side effects associated with a number of herbs is still unknown [2].
It is disconcerting that only 7% of the CAM users in our sample reported being advised on CAM modalities by their “health practitioner”, and the disclosure rate of CAM use to the physician was found to be low (13%). These findings are consistent with previous research, where in a review of qualitative and quantitative studies evaluating the disclosure of patients’ CAM use to medical practitioners, Robinson & McGrail [26] reported disclosure rate to be as low as 23% in some of their included studies. Possible reasons for why patients seem to find it difficult to report their CAM use to their physician include the fear of receiving a negative reaction and disapproval from their physician, believing that their physician did not need to know about their CAM use, and/or because their physician had not inquired about their CAM use [26, 27]. This low disclosure rate of CAM use is alarming and may warrant the need to train physicians on probing their patients on CAM use [22]. Health care practitioners need to become more aware of the increasing prevalence of their patients’ CAM use in order to be able to improve the provision of evidence-based knowledge to their patients concerning the use of these therapies [28].
Our results indicated that sex, age at infertility diagnosis, household income and the type of infertility treatment were independent correlates of CAM use. Males were found to be at higher odds of using CAM. This is in contrast to other studies that found women to be at higher odds of using CAM compared to men [11, 27, 29]. A possible explanation of our finding could be the fact that in the Arab culture, including Lebanon, fertility is linked to manhood, leading male infertility to be an issue for masculinity, marriage and family life [30]. As such, males in this culture may be placing more attention on treatments to enhance their fertility as a mean to restore their “manhood” [30]; such assumption would need to be substantiated in future sociological/ anthropological research.
Our results showed that higher income was associated with lower use of CAM therapies. In previous studies of determinants of CAM use, household income was consistently positively correlated with CAM use [10, 11, 31]. This relationship between CAM use and a high income status in other studies could be attributed to the fact that couples of high income would be more likely to afford the cost of CAM, in addition to their infertility treatments [11]. In those studies, the most widely used CAM were costly modalities, such as acupuncture and massage therapy. In our study population on the other hand, the most widely used CAM modalities were functional foods and prayers among male and female patients, respectively; both of which are therapies that are considered of lower cost, and thus may be less likely to pose as a financial burden to patients of lower income.
Several limitations are to be considered in this study. First, the fact that recruitment of participants took place in an Assisted Reproductive Technologies Unit might have led to an underestimation of the prevalence of CAM use since surveyed subjects have a potential bias toward conventional treatment. Second, given that participants in this study were recruited from one clinical setting raises questions concerning the generalizability of our findings; however, the ART unit at the American University of Beirut Medical Center is considered the largest unit for infertility treatment in Lebanon (as reflected by the high number of cycles it performs per month) and is a major referral center for the treatment of infertility from all other governorates. Third, the cross sectional nature of the study does not allow establishing causality between the various correlates and the CAM use. Finally, the possibility of a recall bias cannot be ruled out in self reports concerning CAM use.
