Evidence for the use of complementary and alternative medicines during fertility treatment: a scoping review

Complementary, supportive and traditional practice experiences of infertile women in Türkiye: a qualitative study

BACKGROUND

In many societies, infertile couples use traditional practices.

OBJECTIVE

This study aimed to determine the complementary, supportive and traditional (CST) practices used by infertile women and their attitudes toward these practices.

METHODS

In this qualitative study, data were collected through individual interviews using a semi-structured form in December 2021. A total of 25 infertile women who applied to the in-vitro fertilization center of a hospital in Türkiye participated in the study. The findings were evaluated by thematic analysis.

RESULTS

The ages of the participants ranged from 25 to 49 years. Three main themes were obtained by the data analysis; "Reasons for using CST practices," "Complementary, supportive and traditional practices used" and "Opinions on the effect of CST practices."

CONCLUSION

Women resorted to complementary and supportive practices for economic reasons, seeking hope, and environmental pressure. Various herbal cures, dietary practices, and religious methods such as praying and prayer amulets, hacamat (cupping), leeches, and various bodily applications were identified as methods commonly used by women. Women were using these methods with the recommendations of people who are not health professionals. It is important to determine the beneficial methods and increase women's awareness of harmful practices. Additionally, although women use many methods for infertility treatment, it should also be noted that infertility is not a female-only problem. Consequently, childless women should be empowered with healthy coping skills.

Trends in acupuncture for infertility: a scoping review with bibliometric and visual analysis

Background

Unexplained recurrent implantation failure and the high cost of assisted reproductive techniques for those experiencing infertility have increasingly resulted in the use of acupuncture. However, the trends and research status of acupuncture on infertility resulting in natural conception have not been systematically summarized. This scoping review and knowledge graph analysis aimed to summarize existing clinical studies on acupuncture for infertility that resulted in natural conception.

Methods

Seven databases, namely, PubMed, Embase, the Cochrane Library, CNKI, VIP, Wanfang Data, and SinoMed, were searched up to August 2023 (updated on 1 April). Two authors independently identified related clinical studies and systematic reviews, and extracted data from included studies on acupuncture for infertility; any discrepancies were resolved by discussion or judged by a third author. A meta-analysis was conducted based on randomized controlled trials (RCTs), and data were synthesized using risk ratios with 95% confidence intervals.

Results

Of the 310 articles meeting the inclusion criteria, 274 were primary studies, 7 were systematic reviews, and 29 were case reports. Reported adverse events included mild ovarian irritation and early signs of miscarriage. Out of the 274 primary studies, there were 40 (14.60%) cases of male infertility and 234 (85.40%) cases of female infertility. Current research highlights on acupuncture for infertility focused on female infertility caused by polycystic ovary syndrome, ovulation disorder, and luteinized unruptured follicle syndrome (LUFS), while acupuncture for male infertility was a hotspot in the early research stage. The meta-analysis also suggested that acupuncture was more effective than human chorionic gonadotropin (HCG) [RR = 1.89, 95% CI (1.47, 2.42), 11 RCTs, 662 participants]. Acupuncture combined with HCG was comparable to HCG [RR = 2.33, 95% CI (1.53, 3.55), four RCTs, 259 participants]. Compared with no treatment, acupuncture resulted in a higher pregnancy rate [RR = 22.12, 95% CI (1.39, 353.09), one RCT, 47 participants]. There was no statistical difference between acupuncture combined with HCG plus letrozole and HCG plus letrozole [RR = 1.56, 95% CI (0.84, 2.89), one RCT, 84 participants].

Conclusion

Current research highlights on acupuncture for infertility resulting in natural conception focused on female infertility caused by polycystic ovary syndrome, ovulation disorder, and LUFS, while studies on male infertility and female infertility caused by blockage in the fallopian tube, thin endometrium, and other factors were insufficient. Well-designed confirmatory clinical studies are still needed as the research hypotheses of most studies were unclear.

The role of oral antioxidants in the improvement of sperm parameters in infertile men

PURPOSE

A variety of pathologic conditions may increase oxidative stress in semen resulting in structural modifications to spermozoa's plasma membrane that interfere with sperm motility, morphology, and count. Antioxidants are currently being marketed to treat male infertility. In semen, antioxidants may decrease oxidative stress and potentially improve sperm parameters. In this narrative, mini-review we evaluated the effectiveness of antioxidants in infertility.

METHODS

This mini-review of the current literature has been carried out through searching of the PubMed and Google scholar databases.

RESULTS AND CONCLUSIONS

The literature review suggests that there is evidence that oral antioxidants such as selenium, carnitine, zinc, coenzymeQ10, vitamins E and C, etc. alone or in combinations, improve sperm count, motility, morphology as well as pregnancy rates in infertile men with idiopathic oligoasthenospermia. Unfortunately, most of these studies are poorly designed, limited by sample size, varying in dosage, differing in primary end points, and most notably lacking live birth data. Importantly, large randomized, well-designed, placebo-controlled trials are needed.

Herbal supplement use among reproductive-aged women in an academic infertility practice

Objective

To address the knowledge gap surrounding herbal medicine and supplement usage patterns and supplement-prescription medication interactions among patients seeking treatment for infertility.

Design

Cross-sectional survey study.

Setting

Academic infertility practice.

Patients

Ninety-five reproductive-aged patients.

Interventions

Not applicable.

Main Outcome Measures

Use of herbal medications and supplements, baseline demographics, history of infertility treatments, and potential supplement-medication interactions.

Results

We surveyed 95 participants with a median age of 35 years. Overall, 68.4% of patients reported ever having used supplements or herbal medicines in the past. Current use of herbal supplements and vitamins was reported by 53.7% and 93.7% of participants, respectively, with a median of 2 (range 19) supplements used per person. There were no significant associations between patient demographics, comorbidities, or infertility treatments with increased rates of supplement use. The most commonly used herbal supplements were: green tea (n = 14), chamomile (n = 12), peppermint (n = 9), turmeric (n = 8), elderberry (n = 7), ginger (n = 7), maca (6) with the most common modalities being pills/capsules (23.8%) and tea (42.3%). The most common reasons for use were: general health and wellness (24.5%), immune support (16.2%), stress (14.0%), and fertility (15.0%). Patients used maca (n = 5), chasteberry (n = 3), goji berry (n = 2), ginger (n = 2), yam-based progesterone (n = 2), and combination product (n = 2) for fertility purposes. A total of 7.9% of patients learned about these products from their general health care provider, and 33.3% of supplements were disclosed by patients to their provider. We identified 41 moderate-risk supplement-drug interactions, with 12 of these interactions attributed to infertility therapies. Based on the interaction checker, the most commonly proposed mechanisms of interaction were CYP3A4 and CYP2C19 inhibition. In terms of safety in pregnancy, cannabidiol and chasteberry were suggested to be "possibly unsafe in pregnancy," and red raspberry leaf "likely unsafe in pregnancy" without direct medical supervision.

Conclusions

We found over two thirds of women seeking treatment for infertility reported past and over half reported current herbal medicine and supplement use. Notably, the Natural Medicines Interaction Checker suggested high rates of moderate-risk supplement-drug interactions and possible harmful effects in early pregnancy. Our results call for further investigation of clinically relevant supplement interactions with infertility therapies.

Botanicals in health and disease of the testis and male fertility: A scoping review

BACKGROUND

Male factor infertility often results from testicular disorders leading to inadequate sperm quantity and quality. Both beneficial and detrimental effects of botanical products, especially herbal medicines, on testicular functions and male fertility have been reported in the literature.

PURPOSE

This scoping review aims to map the main clinical evidence on different impacts of botanical entities on the testis and to critically appraise relevant randomized controlled trials (RCTs) published in the recent 5 years, so as to inform the future.

METHODS

Systematic reviews, meta-analyses and RCT reports on botanical impacts on testicular functions and male fertility were retrieved and synthesized from Pubmed, Web of Science, Scopus, Embase, ProQuest, Cochrane Library and Google Scholar up to 10th May 2022. RCTs published since 2018 were critically appraised against good practice guidelines for RCT and for reporting herbal studies.

RESULTS

We identified 24 systematic reviews and meta-analyses published since 2005, by authors from Iran (25%), China (21%), USA (12.5%) and 9 other countries. All but two were published in English. Only 3 systematic review protocols were identified, all published in English from China in the recent 3 years. We identified 125 RCTs published in six languages, mainly English (55%) and Chinese (42%). They were published since 1994 from 23 countries on all the six inhabitable continents, with China (46%), Australia (8%), USA (8%), India (7%) and Iran (5%) being the leading contributors. 72% and 28% RCTs published in English were on efficacy (botanicals vs placebo) and comparative effectiveness (a botanical vs other treatments), respectively. In contrast, 98% RCT reports in Chinese were on comparative effectiveness, with merely 2% on efficacy. Among all the 125 RCTs, 57% were studies in patients with semen abnormality and/or male infertility, 22% investigated herbal effects in healthy men, 14% were on patients with male sexual dysfunction and hypogonadism, and 7% were conducted in men with non-sexual disorders. Since 2018, 32 RCTs have been published, in English (69%) or Chinese (31%). Nineteen RCT reports from China, India, Japan and Korea all studied herbal formulae while the 13 RCT reports from Australia, Brazil, Czech and Italy, Iran, Malaysia, Spain, the UK and the USA all exclusively studied extracts of a single species. Putting geo-cultural differences aside, gossypol and extracts of Tripterygium wilfordii Hook. f. were found to be detrimental to the testis and male fertility, while the extracts of Withania somnifera (L.) Dunal and traditional Chinese medicine Qilin Pill, etc., might improve testosterone levels and semen parameters, thus could be therapeutic for male sexual dysfunction and infertility. However, all still require further evaluation in view of recurring weaknesses in quality control of herbal materials, RCT design and reporting. For example, only 9%-23% of the RCTs published since 2018 provided information on voucher samples, chemical profiling, herbal authentication and herbal extraction.

CONCLUSION

Research on botanicals and the testis has been reported worldwide, demonstrating clear geo-cultural differences in studied plant species, botanical types, study objectives and quality of research design, implementation and reporting. Due to a few recurring weaknesses in the literature, this study is unable to recommend the use of any specific botanicals, however, current evidence does indicate that botanicals can be double-edged swords to the testis and male fertility. To secure better clinical evidence, future studies must faithfully implement existing and emerging good practice guidelines.

The Treatment of Complementary and Alternative Medicine on Female Infertility Caused by Endometrial Factors

Recently, with the development of the social economy, the incidence of infertility has increased year by year. With its complex etiology and diversified syndromes, infertility has become one of the most important diseases that plague the physical and mental health of women of childbearing age worldwide. Endometrial factors as an important part affecting female reproductive capacity, due to which induced repeated abortion and multiple uterine cavity operations occur, can destruct endometrium, failing to provide a normal implantation environment for zygote, thus resulting in infertility. Many patients failed to achieve expected results after receiving conventional treatments such as hormone therapy, assisted reproductive technology (ART), granulocyte colony-stimulating factor (G-CSF) therapy, and cell therapy, then turn to complementary and alternative medicine (CAM) therapies for help. Aiming at clarifying the effectiveness and mechanisms of CAM therapy in the treatment of infertility caused by endometrial factors, our paper systematically searched and studied present related literature on the PubMed, CNKI, and other databases, focusing on the aspects of clinical application and mechanism explorations and highlighting the therapeutic effects of Chinese herbal medicine (CHM), acupuncture, and moxibustion on such diseases. Moreover, this paper also introduces the CAM treatments of traditional Chinese medicine (TCM) retention enema, neuromuscular electrical stimulation (NMES), photobiomodulation therapy, dietary intervention, and other measures for infertility caused by endometrial factors, in order to provide a reference for subsequent basic research and clinical work.

Progesterone, Myo-Inositol, Dopamine and Prolactin Present in Follicular Fluid Have Differential Effects on Sperm Motility Subpopulations

Considering the challenges surrounding causative factors in male infertility, rather than relying on standard semen analysis, the assessment of sperm subpopulations and functional characteristics essential for fertilization is paramount. Furthermore, the diagnostic value of sperm interactions with biological components in the female reproductive tract may improve our understanding of subfertility and provide applications in assisted reproductive techniques. We investigated the response of two sperm motility subpopulations (mimicking the functionality of potentially fertile and sub-fertile semen samples) to biological substances present in the female reproductive tract. Donor semen was separated via double density gradient centrifugation, isolated into high (HM) and low motile (LM) sperm subpopulations and incubated in human tubal fluid (HTF), capacitating HTF, HD-C medium, progesterone, myo-inositol, dopamine and prolactin. Treated subpopulations were evaluated for vitality, motility percentages and kinematic parameters, hyperactivation, positive reactive oxygen species (ROS), intact mitochondrial membrane potential (MMP) and acrosome reaction (AR). While all media had a significantly positive effect on the LM subpopulation, dopamine appeared to significantly improve both subpopulations' functional characteristics. HD-C, progesterone and myo-inositol resulted in increased motility, kinematic and hyperactivation parameters, whereas prolactin and myo-inositol improved the LM subpopulations' MMP intactness and reduced ROS. Furthermore, progesterone, myo-inositol and dopamine improved the HM subpopulations' motility parameters and AR. Our results suggest that treatment of sub-fertile semen samples with biological substances present in follicular fluid might assist the development of new strategies for IVF treatment.

Empirical therapy for male factor infertility: Survey of the current practice

Background

Empirical therapy is sometimes used by urologists who desire to improve the outcomes for infertility patients. However, the literature on empirical therapies is scarce. Therefore, we aimed to assess the clinical practice of urologists regarding the use of empirical therapy in the treatment of infertility patients.

Methodology

An online survey using Google Forms was used to collect data during the Saudi Urological Association Annual Meeting, February 2019. Additional data were gathered electronically in March and April 2019 and sent to respondents. The study was closed in May 2019. No incentives were provided to the respondents.

Results

A total of 96 (80%) urologists participated in the survey, of whom 69.8% were consultants, and 20.8% were andrology-trained urologists. Empirical therapy was used by 86.5% of urologists for patients with idiopathic oligoasthenoteratozoospermia. The most commonly used empirical therapies were zinc, L-canitine, clomiphene citrate, and L-arginine. The main factors that influenced the selection of empirical therapy were follicle-stimulating hormone, total testosterone, and luteinizing hormone levels.

Conclusion

Empirical therapy was used by more than three-quarters of the participants for idiopathic male infertility. There were no clear guidelines for the ideal therapy to be considered for individual patients while treating empirically. Our concern is that urologists use a wide variety of medications without significant data to support these medications.

Alternative medicine and herbal remedies in the treatment of erectile dysfunction: A systematic review

Objectives: To systematically review and discuss the current evidence from placebo-controlled clinical trials that investigated the use of alternative medicines and herbal remedies in the management of erectile dysfunction (ED). Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-based systematic review using specific keyword combinations was conducted on the PubMed and Scopus databases. Randomised controlled trials investigating herbal medicine in at least one group and using the International Index of Erectile Function (IIEF) as an outcome in patients primarily diagnosed with ED were included for review. Results: Following the literature search, screening and eligibility analysis, a total of 42 articles were included. The 42 articles were categorised as single herb extractions (n = 14), combination herbal formula (n = 5), combination of herbal formula and non-herbal nutraceuticals (n = 7), non-herbal nutraceuticals (n = 5), acupuncture and moxibustion (n = 2), diet and nutrition (n = 3), exercise (n = 5), and topical treatments (n = 1). Based on the results, Korean ginseng, Pygnogenol and Prelox, Tribulus terrestris, Lepidium meyenii, L-arginine, acupuncture and lifestyle interventions were the more predominantly investigated treatments interventions for ED. Conclusions: Panax ginseng, Pygnogenol, Prelox and Tribulus terrestris have promising evidence as herbal products, alongside L-arginine as a nutritional supplement, for ED based on IIEF outcomes, and warrant further clinical investigation. The mechanisms of action remain unclear, but each of these appears to in part increase nitric oxide synthesis. Importantly, improved diet and exercise should be considered, particularly in patients with obesity or diabetes mellitus.

The Efficacy of Complementary and Alternative Medicine in the Treatment of Female Infertility

Female infertility is a state of fertility disorder caused by multiple reasons. The incidence of infertility for females has significantly increased due to various factors such as social pressure, late marriage, and late childbirth, and its harm includes heavy economic burden, psychological shadow, and even marriage failure. Conventional solutions, such as hormone therapy, in vitro fertilization (IVF), and embryo transfer, have the limitations of unsatisfied obstetric outcomes and serious adverse events. Currently, complementary and alternative medicine (CAM), as a new treatment for infertility, is gradually challenging the dominant position of traditional therapies in the treatment of infertility. CAM claims that it can adjust and harmonize the state of the female body from a holistic approach to achieve a better therapeutic effect and has been increasingly used by infertile women. Meanwhile, some controversial issues also appeared; that is, some randomized controlled trials (RCTs) confirmed that CAM had no obvious effect on infertility, and the mechanism of its effect could not reach a consensus. To clarify CAM effectiveness, safety, and mechanism, this paper systematically reviewed the literature about its treatment of female infertility collected from PubMed and CNKI databases and mainly introduced acupuncture, moxibustion, and oral Chinese herbal medicine. In addition, we also briefly summarized psychological intervention, biosimilar electrical stimulation, homeopathy, hyperbaric oxygen therapy, etc.

Low semen quality and adverse histological changes in testes of adult male mice treated with bee venom (Apis mellifera)

Background

Male infertility has been on the rise since the past seven decades. Recently, in Libya, bee venom therapy (BVT) has become a popular method among alternative healthcare practitioners for treating male infertility. However, a literature search did not find any published studies that investigated the use of BVT for infertility treatment.

Aim

To investigate the effect of bee venom on the male reproductive status through measurements of semen quality parameters and testicular histological changes in adult male mice.

Methods

A total of 48 male mice were randomly divided into three experimental groups (which were subdivided into two subgroups with eight mice each) as follows: control, bee venom sting (BVS), and bee venom injection (BVI). The normal control subgroup mice were not subjected to any treatment, while the vehicle control subgroup mice were injected (i.p.) with 200 μl of 0.9% saline solution. In the BVS-treated subgroups, each mouse was stung by one live bee for five times (BVS-5) or seven times (BVS-7) every third day for 2 or 3 weeks. While each mouse in the BVI-treated subgroups received 23 μg/kg in a dose volume of 200 μl BVIs (i.p.) for five times (BVI-5) or seven times (BVI-7) every third day for 15 or 21 days.

Results

The findings of this study showed that repeated bee venom treatment by sting or injection to adult male mice resulted in a significant decline in testosterone levels, sperm count, sperm motility, and a very significant increase in the percentage of abnormal sperm morphology; also, there were harmful testicular histological changes in the structural organization of seminiferous tubules and degenerative changes in the germinal epithelium compared to control group.

Conclusion

The results of this study provide evidence for the low semen quality and adverse testicular histological changes in male mice treated with bee venom. Hence, there is a desperate need for educating alternative healthcare practitioners and infertile couples about the harmful effects of BVT on reproductive status.

Women's Attempts Related to Complementary and Alternative Medicine Use in Infertility Causes and Diagnosis: A Narrative Inquiry

In most cultures of the world, infertility is seen as a disaster and is associated with a myriad of emotional and psychological problems for women. Using Complementary and alternative medicine (CAM) can help treat infertility. The present qualitative study aimed to explore women's attempts related to CAM use in infertility causes and diagnosis. This qualitative study has been carried out through a purposive sampling technique on 78 women living in Neyshabur, Iran. An individual interview and focus group discussions (FGDs) was used to collect data. Purposive sampling was used based on the objective of the study and the characteristics of a population. The data collection was discontinued when saturation occurred, and no new themes or information were explored in the data. Data analysis was performed by content analysis and Atlas T software. This study revealed medical diagnosis and traditional medicine, custom activity, medicine causes, and nutrition issues influence women's view pints and attempt towards infertility and CAM use. Results suggested that infertility should be understood not only in biomedical terms but in light of cultural beliefs and the contingent need for culturally-appropriate supportive CAM. The application of CAM along with medical medicine is an essential element in assisting couples in infertility causes.

Complementary and alternative medicine for urinary tract illnesses: A cross-sectional survey in Jordan

The aim of this study was to assess the extent of Complementary and Alternative Medicine (CAM) usage, especially herbal preparations, in treating urinary tract illnesses, and their perceived efficacy. This was a cross-sectional survey that used a convenience sample of 278 adults who reported having any form of urinary tract illness. During the last 3 months, 105 (37.8%) of participants had used CAM for various urinary tract conditions, of which, 87 (82.9%) used herbal remedies. Urinary tract infections (UTIs) were the most reported urinary condition (n = 77, 73.3%) among CAM users. The most commonly used herbs were, parsley (n = 54, 19.2%), followed by chamomile (n = 29, 10.4%), barley (n = 20, 7.4%) and ginger (n = 18, 6.7%).The study provides an overview of various CAM remedies used to treat urinary tract illnesses in the Jordanian society, which would draw attention to the necessity of conducting interventional studies to evaluate the efficacy and safety of CAMs in treating urinary tract illnesses, either as stand-alone or adjuvant treatment.

Acupuncture and herbal medicine for female infertility: an overview of systematic reviews

Background

Acupuncture and herbal medicine have been used as additional treatments for infertility or as an adjuvant treatment of assisted reproductive technology (ART) in infertility. Many systematic reviews (SRs) and meta-analyses (MA) have been published. This paper reviews the SRs and MA of acupuncture and herbal medicine on infertility to provide evidence for clinical decision making.

Methods

A comprehensive literature search of SRs and MA for the effects of acupuncture and herbal medicine on infertility was conducted using nine databases. Two independent reviewers extracted the data of the selected SR and MA and evaluated their methodological quality using the ‘Assessment of multiple systematic reviews 2 (AMSTAR2)’.

Results

Twenty-one studies were included in this analysis. Eight studies were published in China, and three studies each were published in the USA, UK, and Australia. Conflicting evidence on the efficacy of acupuncture for infertile women has been reported. Herbal medicine for infertile women undergoing ART, women with anovulation, and women with polycystic ovary syndrome helped improve the clinical pregnancy rate. The methodological quality of SRs and MAs evaluated by AMSTAR 2 was low or very low because the protocol or list of excluded studies were omitted.

Conclusion

Herbal medicine tended to be effective in infertility, but acupuncture had low evidence of an effect on infertility. The methodological quality of the published SRs and MAs was underestimated because AMSTAR2 is a more rigorous assessment tool than the previous version.

Reproductive outcomes in women and men using complementary and alternative medicine treatment and not receiving artificial reproductive technology: a systematic review

Purpose

Infertility is a global problem, but only a minority of couples access assisted reproductive technologies due to financial and sociocultural barriers. Complementary and alternative medicine are seen as another option. We aimed to determine the impact of complementary and alternative medicine on conception, miscarriage and live birth rates in couples not receiving assisted reproductive technology treatments.

Methods

The electronic databases EMBASE, PubMed, Web of Science and the Allied and Complementary Medicine Database were systematically searched before March 24th 2020. Reference lists of eligible studies were searched for relevant studies. Eligible studies included trials and observational studies that assessed a complementary or alternative medicine and conception, miscarriage or live births in men or women not undergoing fertility treatment. Data were extracted by two independent reviewers using a pre-designed data collection form. The study protocol was published in the PROSPERO database (CRD42018086980).

Results

Twenty randomized controlled trials were identified, including 2748 individuals. Most studies did not demonstrate any effect of a complementary or alternative medicine on pregnancy, live birth or miscarriage rates. Limited evidence was found for a positive effect of herbal therapies taken by women on conception rates. There was substantial diversity in quality across the studies.

Conclusion

There is limited evidence of the effectiveness of complementary and alternative medicine on improving the chances of conception and live births, or increasing miscarriage risk. Owing to the generally sub-optimal quality and heterogeneous nature of the evidence, rigorous studies are needed to determine the impact of complementary and alternative medicine on fertility.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05836-4) contains supplementary material, which is available to authorized users.

The Effect of N-Acetyl-Cysteine on NRF2 Antioxidant Gene Expression in Asthenoteratozoospermia Men: A Clinical Trial Study

Background

One of the important factor associated with male infertility is high production of reactive oxygen species (ROS). The main function of Nuclear factor erythroid 2-related factor 2 (NRF2) is to activate the cellular anti- oxidant response by inducing the transcription of a wide array of genes that can combat the harmful effects of factors such as oxidative stress. The purpose of this study was to evaluate the effect of N-acetyl-L-cysteine (NAC), as an antioxidant drug, on NRF2 Gene Expression in Asthenoteratozoospermia Men.

Materials and Methods

In this randomized, blinded clinical trial study, included 50 infertile men with asthenoteratozoo- spermia, who received NAC (600 mg, three times daily). Sperm parameters analyzed according to the world health organiza- tion (WHO; 2010). Sperm DNA fragmentation, relative NRF2 expression, and seminal plasma level of antioxidant enzymes were measured by TUNEL assay, reverse transcription polymerase chain reaction (RT-PCR) and ELISA test, respectively.

Results

After NAC treatment, findings showed a significant increase in sperm concentration and motility compared to pre-treatment status, whereas the percentage of abnormal morphology and DNA fragmentation was significantly decreased (P<0.05). A significant improvement in expression of NRF2 gene and antioxidant enzyme levels were ob- served compared to pre-treatment by NAC (P<0.05). Significant correlations were observed between NRF2 mRNA expression level, specific sperm parameters and level of antioxidant enzymes (P<0.05).

Conclusion

The results demonstrated that NAC oral supplementation protected against oxidative stress by enhancing NRF2 expression. This could improve semen parameters quality parameters in asthenoteratozoospermia men (Regis- tration number: IRCT20170830035998N4).

Engagement in Nonbiomedical Practices for Fertility Enhancement: A Scoping Review

Objectives: This scoping review aims to (1) describe the scope and coverage of the body of literature on nonbiomedical practices used for enhancing fertility, (2) summarize and map the existing evidence on the extent and types of nonbiomedical practices used, and (3) examine how the research on this topic has been conducted with particular attention paid to how participants are asked about their use of nonbiomedical practices for fertility enhancement. Design: We conducted a scoping review by which four databases were searched (PubMed, Psychinfo, Socindex, and CINHAL). Articles were screened for inclusion by two researchers through a title and abstract screening followed by a full-text screening. Data were extracted from included articles and results summarized and compared across studies and regions. Results: A total of 32 studies were identified from 16 countries in five regions of the world. The majority of studies were clinic-based, primarily recruiting participants from fertility clinics in urban and suburban areas. More than half of the studies included only women, a few studies included only men, and the remainder of studies included both men and women. Most quantitative studies reported the prevalence of nonbiomedical practice use, which ranged from 8% to 83%; however, there was variation across studies regarding the time frame for which these percentages were derived. Few studies reported on other measures of the extent of use such as duration or frequency. A variety of nonbiomedical practices were identified with biologically based treatments, particularly herbal medicine use, being the most common followed by religious and spiritual interventions. Regional differences were identified. Variation in the wording and format of the question(s) used in survey instruments asking participants about their use of nonbiomedical practices exists and may impact participants' reporting of use. Conclusions: Infertility affects millions of individuals worldwide often with severe social, emotional, and financial consequences. To enhance fertility and, in some cases, overcome infertility, many individuals and couples are engaging in a variety of nonbiomedical practices. This scoping review describes the scope and nature of the existing literature on the use of nonbiomedical practices for fertility enhancement and highlights important gaps and limitations in the conduct of this research. A more comprehensive and inclusive investigation of nonbiomedical practices for enhancing fertility is needed to improve our understanding of how individuals and couples are managing infertility, identify educational and counseling needs, and to improve research related to effectiveness and safety of nonbiomedical practices.

Complementary and alternative medicine use among infertile women attending infertility specialty clinics in South Korea: does perceived severity matter?

BACKGROUND

Complementary and alternative medicine (CAM) use among infertile women is popular in many countries, including Korea. Previous research has repeatedly found more than half of infertile women surveyed use CAM therapies for fertility enhancement and overall well-being. However, there is currently little evidence to support this practice, and this raises the question of infertile women's experiences in the uptake of those modalities and sociodemographic and psychological factors associated with CAM use. Thus, this study aims to explore the perceptions and experiences of infertile women with regard to their use of CAM in Korea.

METHODS

A cross-sectional study was conducted using data from 263 infertile women attending infertility specialty clinics in Seoul, Korea, in June 2012. The survey instrument included 47 questions on the use of CAM, demographic characteristics, health status, and infertility related factors such as duration and type of infertility, experience and satisfaction of conventional treatment, and self-perceived severity of infertility condition. Chi-square test and logistic regression were used for data analysis.

RESULTS

Among 286 respondents (response rate, 95.3%), a total of 263 women were included in the final analysis. 63.5% of respondents used one or more types of CAM modalities during infertility treatment. The utilization of CAM was associated with employment status, duration of infertility treatment, and self-perceived severity of the disease. The most commonly used CAM modalities were multivitamin and herbal medicine, and differences in types of CAM modalities used were found between the group with a higher rating of self-perceived disease severity and the lower perceived severity group.

CONCLUSIONS

High prevalence of CAM use among infertile women was observed in Korea. Our findings support that infertile women's own understanding of their illness and physical condition influences self-care behavior such as CAM use. This calls for an urgent need for further in-depth study of the clinical effects of popular CAM modalities among infertile women when used in conjunction with conventional treatment.

Manual acupuncture for the infertile female with polycystic ovary syndrome (PCOS): study protocol for a randomized sham-controlled trial

BACKGROUND

Polycystic ovary syndrome (PCOS) is one of the most common endocrine diseases for women. Acupuncture is widely used for the infertile female because of it is non-invasive and has fewer side effects, but the powerful evidence for the clinic is still insufficient. Our study intends to explore the effect of manual acupuncture (MA) in the infertile female with PCOS.

METHODS

This study is a randomized, sham-controlled, patient-and assessor-blinded trial and aims to evaluate the effect of MA in women with PCOS and infertility. We will recruit 86 women aged 20-40 years with a diagnosis of infertility with PCOS. Participants will be randomly allocated in a 1:1 ratio to the MA group and the sham acupuncture (SA) group. Both groups will receive real herbal medicine treatment as a basic treatment twice a day for three menstrual cycles, the MA group receive real acupuncture treatment and the SA group received placebo acupuncture treatment (non-penetrating). All patients will receive acupuncture treatment twice per week for three menstrual cycles. The primary outcome is pregnancy rate and secondary outcomes include ovulation rate, sex hormones, insulin resistance index (IRI), PCOS symptoms, and Traditional Chinese Medicine (TCM) syndrome scores. Outcome measures will be collected at baseline, each menstrual cycle, the end of treatments, and six months after the last acupuncture treatment. The present protocol followed the SPIRIT guidelines and fulfilled the SPIRIT checklist.

DISCUSSION

This study will be conducted to compare the efficacy of MA versus SA. This trial will help to evaluate whether MA is effective in increasing pregnancy and ovulation rates of the infertile female with polycystic ovary syndrome.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1800014997 . Registered on 27 February 2018.

Complementary and alternative medicine, medical liability and the proper standard of care

Complementary and alternative medicine raises growing interests among population. Patients have the right to reject conventional medicine and instead look for a different treatment, even if sometimes is a placebo. However, currently this risks being a reckless decision, since the way complementary and alternative medicine is being provided leaves space for fraudulent practices, misleading information, wrong diagnosis, improper treatments and thus severe patient's injuries. This paper will discuss the standard of care to be demanded from providers of complementary and alternative medicine. The paper will sustain that it should be bound to a CAM specific standard of care, expose the reasons for this solution and describe the consequences derived therein. It will conclude that the solution to protect CAM users does not rely in the extension of conventional standard of care to CAM practitioners, but in more regulation and more control for CAM practices and CAM practitioners.