The Prevalence of Complementary and Alternative Medicine Use among Infertile Patients: A Global Systematic Review and Meta-Analysis

Abstract

There is a significant increase in the use of complementary and alternative medicine (CAM) by infertile patients. This study aimed to assess the prevalence of CAM use by infertile patients. This review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The required data were obtained by searching English databases (PubMed and Web of Science) as well as Google Scholar as an additional source of records. We included cross-sectional studies published in English journals up to March 2023 that examined the prevalence of CAM use among infertile patients in different countries. The retrieved articles were independently assessed by two reviewers. Discrepancies were resolved by discussion with the intent to reach a consensus. We reviewed 1192 documents. From these, 29 studies were included in this systematic review and meta-analysis. The results of meta-analysis conducted on 32, 804 infertile patients showed a prevalence rate of CAM use between 26.3% [95% confidence interval (CI): 21.7%-31.3%] and 96.1% (95% CI: 95.7%-96.5%) in various countries. The pooled prevalence rate calculated by the random effects model showed that, overall, 54% (95% CI: 46%-61%) of both infertile women and men used CAM, whereas 55% (95% CI: 47%-67%) of infertile women and 29% (95% CI: 17%-41%) of infertile men reported treatment with CAM. More than half of the infertile patients used CAM. Therefore, healthcare practitioners need to be aware of this practice to better provide care for infertile patients. Further studies should examine the reasons for CAM use by infertile patients.

Introduction

Infertility is a disabling reproductive system disorder. It is a complex, multifactorial condition that is defined as the inability to achieve a clinical pregnancy after at least 12 months of regular unprotected sexual intercourse (1, 2). Additionally, infertility may be referred to as the inability to carry a pregnancy to term and in the delivery of a viable newborn (3). Based on the World Health Organisation, approximately one in every six reproductive age people worldwide experience infertility during their lifetime (4). Infertility can be the result of female factor, male factor, or both; also, it may be due to primary or secondary causes (3, 4).

The prevalence of infertility varies from one region to another (5). The total clinical infertility rate, including primary and secondary infertility, from four Middle Eastern and North African countries is estimated to be 17.2% (6). In the United Kingdom, the reported prevalence rate of infertility is 12.5% among women and 10.1% among men (7). The increased prevalence rate is associated with cohabitation later in life and higher socio-economic status, in addition to experiencing parenthood at an older age (8). Moreover, biological, genetics, infections, lifestyle, and environmental risk factors are associated with infertility in both males and females (9).

There is an increase in couples who pursue appropriate treatments for infertility (10). A study conducted in Britain between 2010 and 2012 reported a prevalence rate for those who sought treatment of 57.3% for women and 53.2% for men (7). Factors that influence infertility treatment include; age; cause and duration of infertility; response to treatment; lifestyle factors such as previous history of fertility, socioeconomic status, sociocultural beliefs, psychological status, overweight, and obesity; and couple's educational level (11-13). Assisted reproductive techniques may be used depending on the cause of infertility. However, for some patients, assisted reproductive technology (ART) is associated with significant financial, psychological, moral, and ethical challenges, and may lead to the discontinuation of treatment (14-17).

The use of complementary and alternative medicine (CAM) by patients and physicians has significantly increased over the past three decades (18). The National Centre for Complementary and Alternative Medicine, which is a division of the National Institutes of Health, defines CAM as “a group of diverse medical and health care systems, practices, and products that are not presently considered as part of conventional medicine.” Complementary medicine (CM) is used along with conventional medicine, and alternative medicine (AM) is used instead of conventional treatment (19). Women who experienced treatment failure for infertility or side effects after treatment have a higher rate of CAM use (20). The results of studies show that CAM use is higher among women compared to men (20, 21). An increased tendency for CAM use for infertility has been reported in different countries; CAM use varies amongst different cultures (22-24). In addition, the rate of CAM use for enhancement of fertility greatly varies. Current international research suggests that between 29 and 96% of infertile women undergo treatment with CAM, along with conventional therapies (20, 24- 43). In some areas, this rate is above 60% (25, 33- 35). The results of a study conducted in Iran showed that nearly 50% of infertile women use CAM (44). Although there are studies that report the use of CAM in infertile women (20, 23, 25-32, 34-42), review studies that discuss CAM use for infertility are limited. These narrative reviews emphasised the consequences of CAM use for treatment of infertility (24, 43, 45-49). Studies conducted by Bennington (45), Weiss et al. (48), and Gutmann (46) in the United States focused on infertility treatment with CAM. Rayner et al. (50) conducted a study in Australia on CAM use for fertility enhancement; another study by Xia et al. (49) in Japan assessed treatment with Chinese medicine. However, none of these studies systematically investigated the frequency of CAM use for infertility and there is no published meta-analysis in this area.

Thus, there is a need for an extensive search of the literature to derive a reasonable estimate of worldwide CAM use for infertility. The research findings can assist with prioritisation of additional research programs, policy-making for planning health promotion programs, and recognising the educational needs of infertile patients. Therefore, this global systematic review and meta- analysis aims to estimate the prevalence of CAM use among infertile patients.

Materials and Methods

Data sources and search strategy

This study was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework (51). We conducted a systematic search of international electronic resources that included PubMed, Web of Science, and other records identified through Google Scholar as an additional source of records. Also, miscellaneous searches were conducted on Google for grey literature such as unpublished manuscripts, conference proceedings, and dissertations. Additionally, the reference list of selected studies were reviewed for additional sources. Medical subject headings with Boolean operators (AND, OR, and NOT) and the related keywords to find titles and abstracts were searched as follows: "Complementary Medicine" OR "Alternative Medicine" OR "Complementary Therapy" OR "Alternative Therapy" OR "traditional Medicine" OR "Acupuncture Therapy" OR "Cupping Therapy" OR "Homeopathy" OR "Yoga" OR "Aromatherapy" OR "Spiritual Therapies" OR "Herbal Medicine" OR "Mind-Body Therapies" OR "Naturopathy" OR "Musculoskeletal Manipulations" OR "Reflex therapy" AND Use OR usage OR utilization OR application OR consumption AND infertility, sterility, fertility, pregnancy in the title, abstract or in keywords of the articles (Table 1). Figure 1 presents the flow chart of the full search strategy for study selection.

Table 1.

Sample of search strategy

MEDLINE vía PubMed:
(("Complementary Medicine" OR "Alternative Medicine" OR "Complementary Therapy" OR "Alternative Therapy" OR "traditional Medicine" OR "Acupuncture Therapy" OR "Cupping Therapy" OR "Homeopathy" OR "Yoga" OR "Aromatherapy" OR "Spiritual Therapy" OR "Herbal Medicine" OR "Mind-Body Therapies" OR "Naturopathy" OR "Musculoskeletal Manipulations" OR "Reflex therapy") AND (infertile[Title/Abstract] OR infertility[Title/Abstract] OR sterility[Title/Abstract] OR fertility[Title/Abstract] OR pregnancy[Title/Abstract])) AND (Use[Title/Abstract] OR usage[Title/Abstract] OR utilization[Title/Abstract] OR application[Title/Abstract] OR consumption[Title/Abstract]) AND (humans[Filter]) AND ((clinical trial[Filter] OR meta-analysis[Filter] OR randomized controlled trial[Filter] OR review[Filter] OR systematic review[Filter]) AND (humans[Filter]))Web of Science((TS=(Use OR usage OR utilization OR application OR consumption)) AND TS=(infertile OR infertility OR sterility OR fertility OR pregnancy )) AND TS=("Complementary Medicine" OR "Alternative Medicine" OR "Complementary Therapy" OR "Alternative Therapy" OR "traditional Medicine" OR "Acupuncture Therapy" OR "Cupping Therapy" OR "Homeopathy" OR "Yoga" OR "Aromatherapy" OR "Spiritual Therapy" OR "Herbal Medicine" OR "Mind-Body Therapies" OR "Naturopathy" OR "Musculoskeletal Manipulations" OR "Reflex therapy" ) and Article (Document Types) and English (Languages)

Fig 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart of the study selection process.

Study selection

The selected studies were checked for duplicate publications. All articles were screened by two independent reviewers (F.S. and R.L.R.). The authors scanned all relevant results and subsequently retrieved the full articles. Thereafter, the references of the articles selected for review and other related systematic reviews were checked manually to search for other articles related to our study. We extracted the necessary data according to a pre-defined checklist (Table 2). The obtained data were independently assessed by the same reviewers. All discrepancies were resolved by discussion until a consensus was reached.

Table 2.

Characteristics of the 25 included studies focused on the "prevalence of CAM use among infertile patients"

Author (Reference), Location, Year	Type of CM	Study method	Sample	Theme					Quality score	Ratio of CAM use (%)
				I	II	III	IV	V
Sharifi et al. (44), Iran, 2022	CAM	Cross-sectional	899 W	√	√	√	√	√	y/y/ y /y/y/y/ y /y /y	49.61
Nwosu et al. (52), Nigeria, 2022	TP	Cross-sectional	263 W	√	√	-	√	-	y/y/ y /y/y/y/ y /y /y	95.40
Babikir et al. (53), Sudan, 2021	CM	Cross-sectional	203 W	√	√	√	√	√	y/y/ uc / uc /y/y/ y /y /y	65.00
Sönmez et al. (54), Turkey, 2021	CAM	Cross-sectional	324 M and W	√	√	-	-	-	y/y/ uc / uc /y/y/ y /y /y	26.6
Ataman et al. (55), Turkey, 2019	CAM	Cross-sectional	797 W	√	√	-	√	√	y/uc/ y /y/y/y/ y / y /uc	36.9
Hwang et al. (33), South Korea, 2019	CAM	Cross-sectional	263 W	√	√	√	√	√	y/y/ y /y/y/y/ y /y /y	63.5
Özkan et al. (36), Turkey, 2018	CAM	Cross-sectional	310 W	√	√	√	√	√	y/uc/ uc /y/y/y/ uc /uc /n	51
Dehghan et al. (24), Iran, 2018	CAM	Cross-sectional	250 M and W	√	√	√	-	√	y/uc/ y /y/y/y/ y /uc /n	49.6
James et al. (23), Sierra Leone, 2018	HM	Cross-sectional	167 W	√	√	√	√	-	y/uc/ y /y/y/uc /uc /y /n	36.5
Hung et al. (41), Taiwan, 2016	CHM	Survey	8766 W	√	√	-	-	√	y/y/ y /y/y/y/ y /y /n	96.17
Porat-Katz et al. (42), Israel, 2015	CAM	Cross-sectional	400 M and W	√	√	-	-	-	y/y/ y /y/y/y/ y /y /y	39.8
Nazik et al. (35), Turkey, 2015	TP	Descriptive study	105 W	√	√	-	-	√	uc/uc/ uc/y/y/y/ uc/uc /n	83
Arentz et al. (25), Australia, 2014	N and HM	Survey	432 W	√	√	√	-	√	y/ uc/y /y/y/y/ y /y /y	>70
Bardaweel et al. (56), Jordan, 2014	N and HM	Cross-sectional	428 M	√	√	√	√	√	y/ uc/y /y/y/y/ y /uc /y	43
Kaadaaga et al. (34), Uganda, 2014	HM	Cross-sectional	260 W	√	√	-	-	-	y/ uc/y /y/y/y/ y/y /uc	76.2
Clark et al. (57), United States, 2013	CAM	Survey	115 M and W	√	√	-	-	√	y/y/ y /y/y/n/n /y /y	91.3
Bardaweel et al. (27), Jordan, 2013	CAM	Survey	1021 M and W	√	√	√	√	√	y/un/ y /y/y/y/ un /y /n	44.7
Kashani et al. (43), Iran, 2013	HM	Cross-sectional	306 M and W	√	√	-	√	-	y/un/ y /y/y/un/ un /y /n	31
Ghazeeri et al. (32), Lebanon, 2012	CAM	Cross-sectional	213 M and W	√	√	√	√	√	y/un/ y /y/y/y/ y /y /y	41
Fang et al. (31), Taiwan, 2012	TCM	Population-based study	14, 080 W	√	√	-	-	√	y/y/ y /y/y/y/ y /y /y	90.8
Edirne et al. (30), Turkey, 2010	CAM	Descriptive study	100 W	√	√	-	-	√	y/ un/ un /y/y/un/ un /n/y	82
Smith et al. (38), United States, 2010	CAM	Prospective cohort study	428 M and W	√	√	-	-	√	n/y/ y /un/y/un/ un /y /y	29
Ayaz and Efe (26), Turkey, 2010	HM	Survey	410 W	√	√	√	-	√	y/un/y /y/y/ y/ un /n /y	27.3
Shannon et al. (37), Irland, 2010	HM	Survey	113 W	√	√	-	-	√	y/un /un /un/y/un/un/n /y	46
Boivin and Schmidt (28), Denmark, 2009	CAM	Cohort study	728 W	√	√	√	-	√	y/y/ y /y/y/y/ y /y /n	30.6
Stankiewicz et al. (39), South Australia, 2007	CAM	Prospective survey	100 M and W	√	√	√	√	√	y/un/ un /y/y/n/ n /y /y	66
Coulson and Jenkins (29), United Kingdom, 2005	CAM	Survey	338 M and W	√	√	-	-	√	y/un/ y /y/y/un/ un /y /y	26.3
Günay et al. (20), Turkey, 2005	TP	Cross-sectional	252 M and W	√	√	-	-	-	y/y/ un /y/y /un/un /y /un	61.5
Zini et al. (40), Canada, 2004	AM	Survey	481 M	√	√	-	-	√	y/un/ y /y/y/ un/ un /y /n	31

CAM; Complementary and alternative medicine, CM; Complementary medicine, HM; Herbal medicine, CHM; Chinese herbal medicine, AM; Alternative medicine, TCM; Traditional Chinese medicine, TP; Traditional practices, N; Nutritional regimen, W; Women, M; Men, ART; Assisted reproductive technology, IVF; In vitro fertilisation, y; Yes, un; Unclear, n; No, I; Prevalence of use, II; User profile, III; Satisfaction with or experiencing adverse effects, IV; Referral and information source, and V; Variety of use.

Inclusion and exclusion criteria

The inclusion criteria comprised peer reviewed crosssectional articles published in English up to March 2023 that examined the prevalence of CAM use in infertile women, men or couples; in cases of both primary or secondary infertility; with no medical history that caused infertility; and no age restrictions.

We excluded expert opinions, commentaries, case reports, editorials, clinical trials, review articles, and book chapters.

Data extraction

During the extraction process, one investigator reviewed the title of the article and the abstract to determine its suitability for inclusion. At this stage, the full text of the selected studies was also checked in terms of the inclusion criteria. A data extraction form was generated based on the related articles, which was then validated and approved by two experts who checked it as a pilot assessment of three articles. Thereafter, two independent checklists were used by the first and second authors to extract the following information: title, authors, year of publication, journal name, study setting, sample size, sampling method, study inclusion criteria, study exclusion criteria, main results, and secondary findings (i. Prevalence of use, ii. User profile, iii. Satisfaction with use or adverse effects, iv. Referrals and information sources, and v. Variety of use). Studies were considered eligible if data were reported on infertile couples, and infertile women and men who did not conceive for more than one year, and used CAM for infertility treatment.

Quality assessment

The quality assessment of the studies was conducted by the two independent reviewers (F.S. and R.L.R.) who used the Joanna Briggs Institute Prevalence Critical Appraisal Tool (58). This tool includes nine items for critical appraisal of the methodological quality of studies. The questions are answered with “yes”, “no”, “unclear”, and “not applicable”. For each criterion met, the study received a “yes” answer. The total number of “yes” answers was counted per study and the larger number of “yes” answers indicated a higher quality study. Any disagreement between the reviewers regarding the methodological quality of the retrieved studies was resolved by consensus.

Data synthesis and analysis

All the included studies reported the use of CAM among infertile patients. Overall estimations were calculated using the random effects models to estimate the pooled prevalence, taking into account the heterogeneity among the included studies. A test for heterogeneity was also applied using chisquare and I² statistics (I² =99.75%, P<0.0001). Random effect was used for cases of heterogeneity (59). The random effects meta-analysis model was chosen for the current study. We employed the inverse variance method to weigh the included studies. This approach assigns greater weight to studies with larger sample sizes or smaller variances, and ensures a robust estimation of the pooled prevalence. We also attempted to perform our analysis based on subgroups by reporting the mean age and type of CAM use. However, the results were heterogeneous, and we decided not to report them. We managed publication biases through the utilisation of funnel plots. Data analysis was performed using Stata software version 17 (Stata Corp LP).

Results

Overview of selected studies

Out of 1192 documents reviewed, a total of 29 crosssectional studies or surveys that measured the prevalence of CAM use in infertile couples were included in this review (Fig .1). A quality assessment of the articles showed that five (17%) articles obtained a score of 100%, 21 (72.5%) articles were above 50% and only three (10.5%) articles received a quality score less than 50%. Articles that were recently published were of higher quality. However, the main issues of the studies were the lack of explanation about participant recruitment; the lack of valid and reliable methods for identification of the study; use of inappropriate measurement tools; and low response rate (Table 2).

Prevalence of use

The selected studies were conducted in various countries, including developed countries including the United States (38, 57), England (29), Australia (25, 39), Denmark (28), Ireland (37), Canada (40), Israel (42), and South Korea (33) as well as developing countries such as Turkey (20, 26, 30, 35, 36, 54, 55), Jordan (27), Lebanon (32, 56), Sierra Leone (23), Taiwan (31), Uganda (34, 41), Sudan (53), Nigeria (52), and Iran (24, 43, 44). In developed countries, the highest rate of CAM use for infertility was reported in Australia (>70%) (25), and the lowest rates were in the United Kingdom (26.3%) (29) and the United States (29%) (38). In developing countries, the highest rate of CAM use for infertility was in Taiwan (96.17%) (41) and the lowest was in Turkey (26.6%) (54).

Our investigation of the reports that included 32 804 infertile couples showed that the prevalence rate of CAM use was between 26.3% (95% CI: 21.7%-31.3%) and 96.1% (95% CI: 95.7%-96.5%) in various countries

Figure 2 shows that the overall prevalence of CAM use in infertile patients was 54% (95% CI: 46%-61%). The random effects model was used because of the heterogeneity of variance (I² =99.75%, Chi² =11 224.21, P<0.001).

Fig 2.

Total prevalence of CAM use among infertile patients (n=29). CAM; Complementary and alternative medicine, ES; Estimated size, and CI; Confidence interval.

The most commonly used CAM treatments in infertile women were herbal medicine (HM) and traditional drugs (24, 26, 27, 33, 38, 44, 52, 54-56); nutrition (56); multivitamins and mineral supplements (33, 56); spiritual healing (27, 55); and acupuncture (24, 38, 39). Accordingly, the findings of some studies showed that the use of CAM was more common among women (20, 21, 27, 54). Only 20% of the studies reported that the patients disclosed their CAM use to their physicians (23, 39, 42, 56, 57).

The rate of secondary findings in these studies were reported as follows: reference to user profiles (100%); satisfaction with or adverse effects (45%); referral and information source (41%); and variety of use (76%) (Table 2).

Subgroup analyses

Figure 3 shows the prevalence of CAM use in infertile couples reported in 10 articles was estimated to be 46% (95% CI: 34%-57%) according to the random effects model (I2=98.16%, Chi² =489.03, P<0.001). The prevalence of CAM use in infertile women in 23 articles was 55% (95% CI: 47%-67%) (I² =99.74%, Chi² =8429.35, P<0.001). Also, the prevalence of CAM use in infertile men in seven articles was 29% (95% CI: 17%-41%) (I² =97.26%, Chi² =219.35, P<0.001) (Figes.4, 5).

Fig 3.

Total prevalence of CAM use among infertile couples (n=10). CAM; Complementary and alternative medicine, ES; Estimated size, and CI; Confidence interval.

Fig 4.

Total prevalence of CAM use among infertile women (n=23). CAM: Complementary and alternative medicine, ES; Estimated size, and CI; Confidence interval.

Fig 5.

Total prevalence of CAM use among infertile men (n=7). CAM: Complementary and alternative medicine, ES; Estimated size, and CI; Confidence interval.

Additionally, we attempted to perform an analysis based on mean age, gender of the participants, type of CAM use, country in which the study was conducted, and article publication year. However, the results were not heterogeneous; therefore, they are not reported in the manuscript.

Discussion

Discussion This study aimed to review the prevalence of CAM use among infertile patients. The findings showed that more than half of infertile patients (54%) used CAM. CAM has been reported to be generally used in both developed and developing countries because of the history associated with their use in these regions (60). Therefore, the development and use of CAM are greatly affected by culture.

Review studies performed on the prevalence of CAM use in infertile people are limited. Although some studies that reviewed CAM use in infertility aimed to examine the consequences of using various methods, none reviewed the frequency of CAM use.

The highest rate of CAM use for infertility was in Australia and the lowest use was in the United Kingdom (29) and the United States (38), as developed countries. In developing countries, the highest rate of CAM use was reported in Taiwan (31) and the lowest in Turkey (54). A review by Rayner et al. (61) supported the results of the present study where eight studies in the review reported considerable variation (29 to 91%) in the proportion of women or couples who used CAM for fertility.

While there were many differences in its usage in different countries, this difference was also seen in different areas of each country and there was a variability in prevalence. For example, the reported prevalence rates of use in various studies were between 29 and 91.3% (United States) (38, 57), 26.6 and 83% (Turkey) (20, 26, 35, 36, 54, 55), 66 and 70% (Australia) (25, 39), 43 and 44.7% (Jordan) (27, 56), 31 and 49.6% (Iran) (24, 43, 44), and 96.17 and 98% (Taiwan) (31). This may be due to the large territories of these countries and the differences in the climate and culture of their different regions, which indicated the widespread use of CAM by infertile patients and the need for increased attention to its use.

The results of various studies showed that, worldwide, women abundantly use CAM during different periods of their reproductive age, and this is similar to the results of our study. Thus, healthcare providers should responsibly advise their patients about CAM use. In our study, which was consistent with a review study performed by Rayner et al. (61), the included studies provided a profile of infertile patients to evaluate the prevalence CAM usage. However, the goals of these two studies were different, and the Hung et al. (41) study mostly focused on the use of CAM for fertility enhancement.

In the current study, the benefits and side effects of CAM in infertile people were not fully addressed. Although reasons for CAM use vary and include the beliefs that these therapies offer safe alternatives to pharmaceuticals, they allow a wide range of choice and control over the childbearing experiences. Moreover, they are congruent with their holistic health beliefs (62). In addition, in a review by Rayner et al. (61), only two studies were related to women’s expectations and satisfaction with the use of CAM for enhanced fertility. In a review conducted by Xia et al. (49) on the use of Chinese medicine for the treatment of female infertility, a small number of randomised controlled trials reported few adverse reactions to CAM. Of note, the use of various CAM methods is mostly affected by the cultural traditions of the health and climate of each region (63). Although CAM is generally intertwined with the infertile patient's life (35, 57, 61), attention to its potential advantages and disadvantages is mostly overlooked.

In the present study, the sources of references and information were mentioned in a small number of articles. In a study by Rayner et al. (61), only three out of eight studies reported the information sources used by their participants.

In the present study, disclosure of the use of CAM to physicians was limited. Clark et al. (57) and Kashani et al. (43) reported that infertile patients did not disclose their CAM use to their therapists. According to a study by Al-Ghamdi et al. (64), only 40.7% of pregnant women disclosed their herbal use to their doctors. However, CAM use by patients who seek appropriate treatment for infertility is increasing and patients must be encouraged to communicate this information to their physicians (46).

The most commonly used CAM in infertile women were: HM, nutrition, multivitamins and mineral supplements, spiritual healing, acupuncture, and traditional drugs. In another review, the most common CAM used for fertility quality enhancement was HM, which was reported in eight of the included articles, along with acupuncture and nutritional advice that consisted of the use of supplements. More unusual types of interventions reported as CAM were religious interventions and spiritual healing, the wearing of fertility accessories, and changes in the patients’ attire and sexual practices (61). A review by Weiss et al. (48) reported that acupuncture was the most commonly used CAM for fertility treatment in the United States. Although such treatments have been used for centuries, controlled trials that have evaluated the efficacy of CAM as infertility treatments are limited. However, some data support the use of both acupuncture and nutritional supplements to increase female fertility (46). The most commonly used traditional medicine (TM) among African pregnant women for the treatment of pregnancy-related symptoms was HM. A lack of access to mainstream maternity care was found as the major determinant for TM use (65).

The findings of the current study showed that CAM use is more common among women. In a survey conducted on 400 infertile patients in the United Kingdom, CAM utilisation in NHS and private clinic settings were more prevalent among women than men (20). The results of a study by Eardley et al. (66) also showed that women were the main users of CAM. Notably, infertile women are in a serious crisis in different societies, which leads them to use various medical or non-medical treatments (17, 46). Because of the global prevalence of CAM treatment among infertile women, it is necessary for healthcare providers to obtain information about their use.

Conclusion

The findings of this study showed that more than half of infertile patients use CAM. The worldwide frequency of CAM use shows that an essential change is needed in the healthcare system and healthcare practitioners should be aware of CAM use by their patients. The integration of CAM with conventional medicine can provide a new path for advancing related medicine to benefit human health and well-being. However, there is a need to perform more studies with robust research methods to distinguish the pattern of CAM use and determine its effectiveness in relation to infertility treatments.

One of the limitations of this study was the lack of access to some of the databases and journals in other countries. Also, the full texts of some articles were not available. In addition, some websites did not have advanced search features. Another limitation was related to the quality assessment of the articles. The answers to some of the quality evaluation items in the text were not mentioned; consequently, this raised the suspicion that the work might have been performed, but not mentioned in the published article. Another limitation was the lack of a common tool used for measuring the frequency of CAM use in these studies. The Begg’s funnel plot of precision was slightly asymmetrical, and this suggested a potential publication bias in the meta‐analysis.

The strengths of the study were the high-quality score of most articles included in the review as well as the use of meta-analysis to perform quantitative synthesis of the obtained data.

Authors’ Contributions

F.Sh., R.L.R.; Contributed substantially in the conception, Design of the study, Carried out study selection, Quality assessment, and Drafted the manuscript. J.J.; Prepared the meta-analysis and Figures 2-5. All authors reviewed and approved the final version of this manuscript for publication.