AUTHORS: ANTHONIA CHINWEUBA (PhD), EKAETTE UDUAK AKAN (BNSc) and IFECHUKWU HOPE IWEOHA (BNSc).
DEPARTMENT OF NURSING, FACULTY OF HEALTH SCIENCE AND TECHNOLOGY, UNIVERSITY OF NIGERIA, ENUGU CAMPUS
TABLE OF CONTENTS
Objective of the Study
Concept of Infertility
Gaps in Orthodox /Conventional Infertility Treatment
General Concept of Complementary and Alternative Medicine (CAM)
Types of CAM used in Nigeria and 2 Other Countries In African Sub-Region (Sierra Leone and Ghana) for Infertility Management 6
Success Rate of CAM in Infertility Treatment
Infertility is defined as the absence of any pregnancy or the inability to maintain pregnancy although couples of reproductive age had engaged in unprotected sexual intercourse at least three to four times a week over a one-year period (Takn, 2012). Infertility has been recognized by World Health Organization as an International Public Health problem affecting millions of families around the world. Faced with higher rates of failed infertility treatments, stress derived from repeated IVF cycles and the costs associated with these treatments, may women now seek different treatments in order to increase their chance of experiencing a healthy pregnancy and to manage their infertility-associated stress.
Fertility issues are primarily investigated by Family Practice Physicians and gynecologists (i.e. diagnostic investigations, endocrine disorders, anovulatory conditions) with unresolved infertility ultimately treated by reproductive endocrinologists using assisted reproductive technologies (ART). For some patients, ART presents significant financial, psychological, moral and ethical challenges which may lead to discontinuation of treatment. As medicine, in particular ART, becomes increasingly technological, patients are choosing complementary and alternative medicine (CAM); perceived as more natural with less side effects. The National Centre for Complementary and Alternative Medicine (NCCAM) defines complementary and alternative medicine (CAM) simply as various medical and healthcare interventions, treatments, products or disciplines that are not considered as a part of conventional medicine (National Centre for Complementary and Alternative Medicine, 2012).
The CAM applications that are used in infertility vary based on the country and geographical regions. According to the study by Clark et al. the most common CAM practices recommended by doctors during infertility treatment were determined to be acupuncture, massage, nutritional supplements, praying, psychotherapy, physical exercise, multivitamins, herbs, mineral supplements, natural methods, and meditation (Clark, Will, Moravek, Xu X and Fissea, 2013). This work aims to describe the CAM methods which women admitted to using after they were diagnosed with infertility in Nigeria and some West Africa sub-regions.
Objective of the Study:
1. To Explore the Concept of Infertility.
2. To Examine the General Concept of Complimentary and Alterative Medicine (CAM)
3. To Explore the gaps in Orthodox/Conventional Treatment of Infertility
4. To Explain the Use of Complimentary and Alterative Medicines (CAM) in the Management of infertility in Nigeria, Sierra Leone And Ghana
5. To Examine the success rate of CAM Methods in Infertility Management in Nigeria, Sierra Leone And Ghana
Concept of Infertility
Infertility is a complex, multifactorial condition characterized by the absence of conception following one year of unprotected sexual intercourse. Biological, genetic, infectious, lifestyle and environmental risk factors are associated with both male and female infertility (OReilly, Sevigny, Sabarre & Phillips, 2014). It is considered a social and public health problem that affects the health and wellbeing of millions of couples worldwide. The World health Organization (WHO) defines infertility as the failure to conceive after 12 months of regular unprotected sexual intercourse in the absence of known reproductive pathology. Globally, in the past two decades, the absolute number of couples affected by infertility has increased from 42.0 million in 1990 to 48.5 million in 2010 (Mascarenhas, Flaxman, Boerma, Vanderpoel, and Stevens, 2012).
In Sub-Saharan Africa, infertility still receives less attention and is of low priority in the continents reproductive health agenda despite its huge psychosocial and economic impact on individuals, families, and communities. It is believed that increased population growth due to high fertility rate in the region has masked the spotlight infertility deserves (Patel, 2016). Paradoxically, the prevalence of infertility in certain Sub-Saharan African countries is reported to be more than 30% (Nachtigall, 2006). Infertility or childlessness in most developing countries including Africa is gender biased with the female partner often cited as the cause of the problem (Mascarenhas, Flaxman, Boerma, Vanderpoel, and Stevens, 2012). In many of these communities, women are target of psychological and physical abuse by their families and communities. Such an abuse can be in the form of marital instability, divorce, social isolation stigma, economic deprivation, and intimate partner violence (Dyer, Abrahams, Hofman, 2002).
Bearing a child in Africa not only defines womanhood but also brings dignity and respect to the family as well as securing rights of property and inheritance. It also serves to guarantee the continuation of the family lineage and future social insurance against poverty in a region where social security schemes during old age are uncommon (Hollos and Larsen, 2008). Family and societal pressure to conceive and the increasing odds of reduced fertility due to aging, together with the inability to access high cost conventional medical therapies such as In-vitro fertilization (IVF) and assisted reproductive technology (ART) may influence a womans decision to seek complementary or alternative health approaches in order to conceive (Ombelet, Cooke, Dyer, Serour, and Devroey, 2008).
GAPS IN ORTHODOX /CONVENTIONALINFERTILITY TREATMENT
CAM practitioners identified lack of emotional support in the conventional medicine as the major unmet need for infertility patients.
Lack of education around lifestyle management, social networks and use of an integrated approach were also mentioned.
Perceived infertility patients motivations for CAM treatment to be related to their strong desire to achieve pregnancy and dissatisfaction with ART, practitioners recognized infertility and ART as significant contributors to patients emotional distress.
Patients diagnosed with unexplained infertility are at particular risk for depression, distress and difficulty reaching acceptance of their infertility.
Discontinuation of ART is not only associated with financial, relationship and psychological stressors but the burden of treatment itself.
Physical pain and discomfort, adherence to injection protocols along with clinic environmental factors (e.g. poor organization, depersonalized care, limited time for discussion) may all contribute to infertility patients dissatisfaction with ART.
Non individualized approach and lifestyle management as mitigating some of their patients fertility-related emotional distress among others.
Integration of formal counseling during the infertility treatment process for patients who struggled with some debilitating symptoms was also recommended.
UK, Australian and New Zealand acupuncturists also recognized the significant emotional toll of infertility treatments on patients, alleviating distress through CAM and patient support
CAM treatment is often connected to cultural beliefs, self and home care which makes patients feel protected and safe.
GENERAL CONCEPT OF COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)
ComplementaryMedicine: These are treatments that are used along with standard Medicinal treatment but are not considered to be standard treatments eg using acupuncture to help lessen some side effects of cancer treatment: this include natural products. Altanative Treatment: These are treatments used instead of standard medical treatments eg using special diet to treat cancer instead of anticancer drugs prescribed by an oncologist. They are not part of the conventional medicine eg Acupuncture, Herbal medicine.
Integrative Medical is a total approach to medical care that combines standard medicine with CAM proactive that have been shows to be safe and effective. The treat the patients& spirits they treat the whole person instead of an organ CAM is based on the belief that a medical care provider has to treat. It is usually less invasive ie rely less on surgeryThis describes any practice which aims to achieve the healing effects of medicine, but which lacks biological plausibility and is untested or untestable (White 2015).
Complementary and Alternative medicine (CAM), integrative medicine (IM) or holistic medicines are among many rebreeding of the same phenomenon. Alternative therapies share in common that they reside outside medical science, and rely on pseudoscience. It is distinct from experimental medicine, which employs the scientific method to test plausible therapies by way of responsible and ethical clinical trials, producing evidence of either effect or of no effect. Research into alternative treatments often fails to follow proper research protocol and denies calculaton of prior probability, providing invalid results. Traditional practices become "alternative" when used outside their original settings without proper scientific explanation and evidence. Frequently used derogatory terms for the alternative are new-age or pseudo, with little distinction from quackery.
Complementary and Alternative Medicine (CAM) refer to a heterogeneous group of practices that are defined by The National Centre for Complementary and Alternative Medicines as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (National Centre for Complementary and Alternative Medicine, 2012).
Traditional, Complementary and Alternative Medicine (TCAM) refers to a set of healthcare practices (indigenous or imported) that are delivered outside of the mainstream healthcare system.(WHO,2014) In the African setting it may encompass local herbal medicines or products, indigenous healthcare practices (traditional bone setting), as well as imported complementary and alternative medicine products and practices (eg, acupuncture or chiropractic). The management of infertility is most widely acceptable in the orthodox system. However, complementary and alternative means of treatment (CAM) exists in most part of the world generally and Nigeria particularly Though the orthodox method involves medical as well as surgical treatments, CAM on the other hand involves a good lot of methods. This write up is focused on discussing reasonably these methods briefly but with greater emphasis on CAM. It also examine the nursing implications after close analysis of the integrated approach to infertility management.
CAM practitioners carry out or use interdisciplinary, individualized, holistic infertility treatment approaches with patients supported by stress and lifestyle management. Diagnostic investigations often included physical assessments, use of lifestyle, clinical history questionnaires and fertility hormone laboratory tests. The practices involves herbal treatments, acupuncture, psychotherapy etc. Studies performed in Western countries such as Ireland and the USA have found that CAM practices such as acupuncture, exercise, herbal medicine and psychotherapy were more frequently used in infertility treatment. The methods most frequently used by the women in some western countries were spiritual support and herbs which were similar to those practiced in Nigeria. Prevalence of CAM among infertile couples reported in different parts of the world, a lower percentage (29%) was reported in a sample of 428 infertile couples in Northern California . On the contrary, higher utilization per- centages, 66% and 82% were reported by 100 infertile couples in South Australia and 100 Turkish women in Turkey, respectively. Apparently, the variation observed may be attributed to cultural and socio- economic differences between countries. Furthermore, expanded recognition and availability of CAM in developing countries might contribute to the relatively high prevalence of CAM for infertility treatment.
CAM in Africa
Africa is one region of the world in which TCAM has long been held to be widespread, with a considerable number of its population relying on it to maintain their health or prevent and treat communicable and non-communicable diseases.(WHO, 2000) The economic influence of TCAM is extensive, contributing at least R2.9 billion (US$2.2 million) to the South African economy alone.(Mander, Ntuli, Diederich, 2007). Recently, the here has been global interest in the use of CAM as a health care option. World Health Organization (WHO) and other studies have reported that more than three quarters of the worlds population rely upon complementary and alternative medicine (CAM) for health care (WHO, 2014).
The prevalence of CAM in developing countries is often connected to cultural beliefs and practices that lead to self-care, home remedies or consultation with traditional and religious healers. Additionally, dissatisfaction with outcomes associated with conventional medicine; the apparent acceptance of naturalness and harmlessness of CAM as well as the belief that use of CAM therapies allows users more active involvement in treatment and in healthcare decisions largely contribute to the wide prevalence of CAM in developing countries. (Rayner, McLachlan, Forster, Cramer 2009, Özcan and Beji, 2016)
USE OF CAM IN NIGERIA, SIERRIA LEONE AND GHANA IN MANAGEMENT OF INFERTITY
Infertility has been identified by the WHO as an international public health concern, affecting an estimated 72.4 million women in year 2007 (Mascarenhas, Flaxman, Boerma, Vanderpoel, and Stevens, 2012). While assisted reproductive technologies (ART) serve as promising treatment options for these patients to achieve parenthood, they do not always prove to be successful, and the expense associated with their utilization has proven to be a burden, leaving couples feeling desperate to try anything to conceive (Vayena , Rowe, Griffin, 2002). Nigeria, Ghana and Sierra Leone have been shown to house one of the fastest growing markets of CAM products in the world (Gruenwald, Herzberg, 2002). As with most countries in Africa, traditional medicine use is common with considerable amount of the population using it to treat various health conditions such a malaria, diarrhoea, respiratory infections and hypertension. Unorthodox fertility services are widespread in Africa and are often provided by traditional medicine practitioners. Only few researches across Africa have focused on this issue with relatively high use reported in these studies. A Nigerian study reported that more than two-thirds of infertile couples (69%) seek care from a traditional complementary medicine practitioner (Ola, Aladekomo, and Oludare, 2008) while a Ugandan study reported 76.2% prevalence of herbal medicine use among women seeking infertility care (Kaadaaga, Ajeani, Ononge, 2014). Other countries in Africa widely utilizing CAM include Rwanda, Uganda, Zambia, South Africa and Tanzania
The prevalence of CAM in the above named countries is often connected to cultural beliefs and practices that lead to self-care, home remedies or consultation with traditional and religious healers. Additionally, dissatisfaction with outcomes associated with conventional medicine; the apparent acceptance of naturalness and harmlessness of CAM as well as the belief that the use of CAM therapies allows users more active involvement in their treatment and in healthcare decisions largely contribute to the wide prevalence of CAM in these countries. (Rayner, McLachlan, Forster, Cramer 2009, Özcan and Beji, 2016). Slight variations observed may be attributed to cultural and socio- economic differences between countries. The CAM management methods Furthermore have revealed a heterogeneous management system across regions with like philosophical underpinnings, The expanded recognition and availability of CAM I n developing countries might contribute to the relatively high prevalence of CAM for infertility treatment similarity globally.
General Approaches to Use of CAM In infertility management In African Sub-Region
Integrated approach to infertility managements have been critically observed with diagnostic investigations often including physical assessments, use of lifestyle-clinical history questionnaires etc. The treatments optionsinclude the followings;
1) Herbal Remedies (HRs) are the most frequently used and acknowledged methods among other modalities of CAM, it is the most prevalent form of traditional and complementary medicine use in Sub-Saharan Africa especially Ghana, Nigeria and Sierra Leone. Reasons for its popularity is attributed to its low cost, accessibility, alignment with patients cultural and religious values and perceived efficacy and safety as well as dissatisfaction with conventional healthcare. As with most countries in Africa, traditional medicine use in Sierra Leone is common with considerable amount of the population using it to treat various health conditions such malaria, diarrhoea, and respiratory infections and hypertension.
2) Unorthodox Fertility Services: these are widespread in Africa and are often provided by traditional medicine practitioners. According to several surveys, herbal medications seem to be mostly preferred for chronic health conditions which lower quality of life in developing countries; women always use them for conception eg sitting over water/vapour, food and drinks, placing an object or concoctions directly into the vagina, materials applied to hygienic pads, practices recommended by the local health practitioners as seen in the cryptic pregnancy. Heat-treatment therapies and other procedures including doing exercises, following a diet, acupuncture, hypnosis, meditation, and psychotherapy, herbs are most widely used for infertility management in Sub-Saharan Africa, its popularity are attributed to its low cost, accessibility, alignment with patients cultural and religious values, and perceived efficacy and safety as well as dissatisfaction with conventional healthcare. Herbal therapies include plants that are consumed for their claimed health benefits, and encompass remedies such as ginger, garlic, black seed, ginkgo, feverfew, and Asian ginseng. Based on the WHO definition, it includes herbs (such as leaves, flowers, fruits, seeds, stems, wood, bark, roots, or other plant parts which may be entire, fragmented, or powdered), herbal materials (such as fresh juices, gums, oils, dry powders obtained by procedures like steaming, roasting, etc.), herbal preparations (finished herbal products including powdered herbal materials or extracts, tinctures, and oils of herbal materials, and also those made in the form of beverages), and finished herbal products that contain active ingredients as parts of plants, or other plant materials or combinations are quite often utilized in they managements procedures. Mascarenhas et al (2012)
3) Religious/Faith Healings or Spiritual Therapy: This involves any religion-related activity practiced to improve fertility. The widespread religious health-seeking behaviors involve individuals or groups praying or reciting religious texts to seek cure. Individuals may drink holy water from spiritual healers, fast or undertake pilgrimages to holy places including graves to seek forgiveness of sins and alleviation of barrenness. At some holy places, people light candles or bind pieces of their cloths to the trees with a wish to conceive.
4) The Social Context Approach:this is one of the private social relationship upon which infertility is widely managed. Under this context specifically practiced in the southern part of Nigeria and in Ghana, a family known to be infertile restrains their female daughters from getting married officially to any man. However, they are allowed to have unofficial engagement with one known man or more and therefore conceived and such child when given birth to remains in the mothers.
Other married couples who suffer infertility in such communities do have and agreed social relationship which may range from the wife openly marrying another wife for the husband through which children are brought into such families. Again the infertile couples can agree for each other to have known or unknown sexual relationship with opposite sex, where pregnancy will result and such will be delivered into such families. Mention is made of one of such families in the south east upon which a husband mentioned same to a Whiteman and arranged for the wife and the white man, that lead to the cast system that have persisted for long.
5) Use of Functional Foods and Dietary Supplements:Include foods that are perceived as having a fertility-enhancing property beyond their basic function; such as eggs, honey, and foods containing essential fats (e.g. fish, nuts walnuts, onions, figs and seeds). Dietary supplements on the other hand, include vitamins and minerals, over the counter supplements, the counter supplements are fish oils such as salmon and cod liver oils, omega-3 supplements, and products from general nutrition centers (Takn 2012)
6) Other Folkloric Methods: Include Eating the cooked reproductive organ (uterus) of the female rabbit (Oryctolaguscuniculus) before sexual intercourse, Sitting over water/vapour of hibiscus, plantain or milk, Appling materials to a hygienic pad such as egg yolk and Placing an object directly into the vagina (sheep tail fat, hibiscus, honey, plantain, turmeric and herbal suppositories).
7) Heat-treatment and Massage Therapies: are also employed. This is usually by applying hot vacuum glasses on the groin, applying heat on the abdomen, and wrapping the pelvic region with warm wetted clothes or pads. Being under a lot of stress can affect ovulation and the regularity of periods. Here's where massage may help,. It help you to de-stress, sending blood and oxygen to the massaged parts of the body, and warming and relaxing muscles.
8)Psychotherapy: The practice of infertility counseling has become more sophisticated and widespread over the past decade. Women in particular suffer from psychological stress when diagnosed with infertility which has mental, social, and reproductive consequences and has been found to have responded to Psychosocial and psychiatric interventions known to not only prevent and lessen various mental problems, but also to play a positive role in physical and reproductive health. Here patients are given antidepressants, equipped with stress management skills, gradual relaxation training, restructuring, and eliminating of negative automatic thoughts and dysfunctional attitudes to infertility. Mascarenhas et al (2012) They are educated on the side effects of infertility treatment medications and the impact of hormone shifts on psychological well-being. These are helpful with differential diagnoses among grief, depressions, and stress; in assessing psychological preparedness; and in determining the acceptability and suitability family-building alternative for individuals, couples, and reproductive collaborators.
9) Weight Loss: Obesity affects ovulation, response to fertility treatment, pregnancy rates and outcome. Weight loss is believed to improve live birth rates in overweight patients with infertility. Here, Patients are given a "meaningful" weight loss goal, provided diet and exercise recommendations, metabolic screening, and pharmacologic intervention when indicated (Takn 2012). Weight loss leads to high spontaneous conception rate as well as with ovulation induction therapy and improves the pregnancy outcome. Weight loss should be considered as a first option for women who are infertile and overweight.
10) Acupuncture: Acupuncture is increasingly being used in reproductive medicine. The positive effect of acupuncture in the treatment of sub fertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction. Acupuncture may help restore ovulation in patients with polycystic ovarian syndrome. Acupuncture can be considered as an effective alternative for pain relief. Acupuncture is based on the theory that there is a natural flow of energy through your body called qi (pronounced "chee"). The practice of stimulating special points in the body with fine needles is said to free up this flow of energy, helping the body to function better. Smith, Ussher, Perz & Carmady. (2011)
11) Meditation: Meditation, massage and traditional bone setting relaxation can help women experiencing the challenges of infertility. The practice of meditation and relaxation can help increase the clarity of the mind, maintain healthy body chemistry, and give patients the patience to undergo the rigors of infertility treatments. When one understands and can attain physical relaxation, one tends to feel better about the body itself, and begins to treat the body with more respect. This understanding can lead to healthier lifestyle habits as well as increased sensitivity regarding symptoms and body processes. This is beneficial to both doctor and patient as the patient can report with more clarity and sense cycles and physical issues more readily. This method also seems to be a good preventive management option.
12) Reflexology: Reflexology is a relaxing and calming therapy involving foot and hand massage. It can have a positive effect on quality of life and reduce stress and anxiety. This could be helpful when trying to get pregnant, as stress and anxiety may make it harder to conceive.
13) Therapy with Crystal Jewelleries: Crystal therapists claim crystals have electromagnetic charges that encourage bodys processes to work better. The theory is that this may help the body to be more receptive to conceiving a baby. There's no evidence that it works, but it's a relaxing, "me-time" therapy. If one do not fancy crystal therapy crystal jewelry may be another option.. Some women believe that simply wearing crystals can bring the same benefits as crystal therapy. Jewelry may be sold with the claim that they've had a fertility spell said over them. There is no evidence to show that wearing crystal jewelry affects fertility. However, one may at least feel that shes taken a positive step towards getting pregnant.
14) Hypnotherapy: Hypnotherapy is also used to help relax and reduce anxiety. The deep relaxation can possibly help to achieve the feeling of being less stressed and more in control of personal life, thereby being more empowered about his or her ability to conceive. Mindfulness which is about focusing ones awareness on the present moment, whatever one is doing, while at the same time accepting his or her thoughts and feelings. It allows one to take a step back, and consider things without the rush of emotions that can cloud thoughts when one encounter a problem. If one is stressed out as each month goes by without a positive pregnancy. One may benefit from practicing mindfulness. It's known to reduce anxiety, which in turn, can improve conception chances.
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