We found that CAM was used as a fertility treatment by 29% of 428 infertile couples in Northern California after 18 months of observation. Acupuncture and herbal therapy were the most commonly utilized modalities for the treatment of infertility (23% and 18%, respectively) while a much smaller fraction of study participants had utilized a form of body work or meditation. This utilization is congruent with reports of 31% CAM use among almost 500 infertile men in Canada (15
) and 40% use by 400 women in Great Britain (16
). Although Stankiewicz reported that 66% of 100 infertile couples in South Australia had used CAM (11
), their higher utilization may be due to the inclusion of multivitamins as a CAM therapy. Cultural and socioeconomic differences may explain the higher prevalence (62%) of traditional medicine used for infertility among 252 couples in Turkey (17
Participants in the current study utilized CAM after having had an initial consultation with a reproductive endocrinologist, a finding congruent with van Balen’s Dutch study suggesting that couples consider mainstream medical treatments first but go on to pursue CAM after an initial infertility evaluation (18
). However, Nachtigall’s report that low-income infertile Latino couples frequently utilize traditional medical remedies (such as teas and massage) in parallel with western medical interventions suggests the influence of cultural factors within specific patient populations (19
). Although we did not observe racial differences in our data, this may have been due to the low proportion of minorities in our sample; other investigators have detected significant racial and ethnic differences in CAM use in non-infertility populations (20
The expanded recognition and availability of CAM is a relatively recent phenomenon in the industrial West. Motivations underlying the use of CAM as a fertility treatment have received limited attention. Although we did not address patients’ decision-making directly in this study, CAM users were more likely to be older, have a higher income, have used IVF, have a more positive attitude toward CAM use at baseline, and have failed to achieve a pregnancy. While it seems clear that a pre-existing positive attitude toward CAM would increase the likelihood of its implementation, the identification of age, income, treatment choice, and pregnancy status as variables associated with increased likelihood of CAM use raises several interesting questions.
Although age was associated with CAM use in bivariate models, this effect disappeared after adjustment for pregnancy status. It may be that, as older women have lower per cycle pregnancy rates, they are more likely to search for alternatives that improve their chances of achieving a pregnancy. Older women, with correspondingly higher incomes than younger women, may be better able to pay for additional fertility treatments. While it is possible that patients utilize CAM as a lower cost treatment alternative, our data suggest the opposite. Higher income couples choosing IVF were more likely to use CAM, not lower income couples as would be expected if CAM were chosen as a lower cost alternative to mainstream fertility treatments.
Consistent with the hypothesis that pregnancy status influences CAM use, Van Balen found, through face-to-face interviews with infertile couples, that reasons for using CAM fell into three broad categories: increasing the chances of having a child, failure of standard fertility treatments, and a desire to avoid standard medical fertility treatments (18
). Rickhi et al found that a baseline predisposition to CAM use or failure of other medical therapies were strongly related to CAM use in a non-infertility population (22
). Similarly, among 250 individuals in three CAM practices in the United Kingdom, several factors were found to be associated with choosing CAM: a belief in the value of treating the whole person, a positive opinion of CAM, the belief that CAM would be more effective than mainstream medicine, the ineffectiveness of mainstream medicine, the fear of potential adverse effects of mainstream medicine, and the belief that CAM treatment would allow for more direct patient participation in one’s care (6
). A unifying theme was that failure of mainstream therapy was commonly associated with CAM use, a hypothesis supported by our current study.
In contrast, Boivin and Schmidt, in their study of 728 infertile couples in Denmark, found that CAM use was associated with a significantly lower pregnancy rate among CAM users (31%) vs. non-CAM users (42%), suggesting that CAM use affected pregnancy outcomes (23
). The authors are careful to point out that causality cannot be convincingly proven by their results. The direction of causality cannot be conclusively determined from our data because couples’ pregnancy status and CAM use was not obtained for couples that had already achieved a pregnancy in earlier interview periods. With the relatively high prevalence of CAM use and many unanswered questions, there is a pressing need to understand the safety and efficacy of CAM use as a fertility treatment. To date, studies of CAM as a treatment for infertility have demonstrated benefit (24
), ineffectiveness (25
), and harm (15
The self-selected nature of our recruitment process and recall bias on the part of participants may have resulted in over or under-reporting of the prevalence of CAM utilization in this study. The proportion of male factor infertility was relatively low in our cohort. This likely reflects the fact that participants were recruited from couples presenting to reproductive endocrinology clinics. Given these factors, it is possible that results from our study cohort are not generalizable to other infertility populations. The relatively small number of minorities in our study limits our ability to characterize use of CAM for fertility purposes in non-white individuals. Furthermore, the present study was not designed to reveal a real or perceived efficacy of CAM use for the purposes of establishing pregnancy. That acupuncture and herbal medications were the most utilized CAMs may reflect greater access to these therapies because of their relatively high availability in Northern California.
Nevertheless, to our knowledge this is the first reported prospective study of predictors for CAM use among infertile couples in the United States. Further studies on minority groups and from other geographic regions will further illuminate what factors may drive patients to seek alternative medical treatments for infertility. Additional well-designed and controlled studies will be required to demonstrate whether CAM treatments are likely to be of benefit or detriment to men and women seeking treatment for infertility.