Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12319 Prevalence and correlates of complementary and alternative medicine utilization among infertile women attending selected fertility clinics in Khartoum state Masani Elmahdy,1 Faiza Ali Nasor2 1College of Nursing, Gulf Medical University, Ajman, United Arab Emirates; 2Obstetrics and Gynecology Nursing Department, Faculty of Nursing, University of Khartoum, Sudan Abstract Infertility poses multifaceted challenges, prompting many women to explore complementary and alternative medicine (CAM). This study investigated CAM prevalence and types among infertile women in Khartoum. A descriptive cross-sectional study was conducted, involving 253 women. Data was collected through structured interviews, and descriptive and inferential sta- tistics, with a significance level set at p>0.05. The mean age of the participants was 31.59±6.9 years, with 53.8% being graduates, 54.5% diagnosed with primary infertility, and 45.5% with second- ary infertility. CAM usage was reported by 52.2% of participants, with herbal treatments being the most prevalent (e.g., fenugreek 26.9%, argell 20.2%). Spiritual healing (11.4%) and folkloric methods (9.5%) were also noted. Most users (76.5%) did not dis- close CAM usage to healthcare providers, citing beliefs in safety (56.8%) and effectiveness (39.4%). Family (72%) and friends (46%) significantly influenced CAM use. Infertility duration and rural residence were associated with CAM usage (p=0.002). The study underscores a high prevalence of CAM usage among Sudanese infertile women, primarily herbal remedies, and empha- sizes the importance of healthcare providers engaging patients in CAM utilization. Introduction Infertility is generally defined as not being able to get preg- nant (conceive) after one year (or longer) of unprotected sex. About 6% of married women aged 15-44 in the United States are unable to get pregnant after one year of trying (infertility).1 The World Health Organization (WHO) demographic studies also show that in Sub-Saharan Africa, more than 30% of women aged 25-49 suffer from secondary infertility.2 WHO defined traditional medicine as “diverse health practices, approaches, knowledge, and belief incorporating plant, animal, mineral base medicine, spiritual therapies, and exercises applied singularly or in combina- tion to maintain wellbeing, as well as to treat, diagnose, or prevent illness. The term complementary/alternative/non-conventional medicine is used interchangeably with traditional medicine in some countries”.3 As efforts to have a child fail, couples experi- ence several socio-emotional outcomes in which, women endure more painful emotional experiences because in many countries, being a woman means to be a mother. In addition, psychological outcomes incurred by couples as a result of infertility treatment and costs impose more pressure on them for Assisted Reproductive Technologies (ARTs), such as In Vitro Fertilization (IVF). Nevertheless, couples have a greater tendency toward nat- ural treatments than aggressive ones such as IVF. As much as ARTs are not always successful, couples are inclined to experi- ence treatments other than conventional ones, including Complementary and Alternative Medicine (CAM).4 People facing infertility concerns are increasingly turning to the use of ARTs. Correspondence: Masani Elmahdy, College of Nursing, Gulf Medical University, Ajman, United Arab Emirates. Tel.: +971566585368. E-mail: masani.elmahdy@gmail.com Key words: CAM, alternative medicine, herbal medicine, infertility, women. Contributions: ME, FAN, conception or design of the work, drafting of the article, critical revision of the article, final approval; ME, data collec- tion, data analysis, and interpretation. The authors state that no artificial intelligence-assisted technologies (such as Large Language Models, chatbots, or image creators) were used in the production of submitted work. Conflict of interest: the authors declare that they have no competing interests. Ethics approval and consent to participate: ethical approval from the Khartoum Faculty of Nursing University Sciences institutional review board was obtained. Informed consent: informed consent from each research candidate was obtained, and confidentiality was maintained. Funding: none. Availability of data and materials: not applicable. Acknowledgments: the authors praise Allah the Almighty for giving us the determination and the strength to complete this study. They would like to express appreciation and gratitude to the fertility center’s staff members, managers, and the participants for their cooperation and also, to acknowledge the University of Khartoum, faculty of Nursing Sciences, faculty, and staff for their cooperation. Received: 29 January 2024. Accepted: 19 April 2024. Early access: 12 June 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12319 doi:10.4081/hls.2024.12319 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 362] [Healthcare in Low-resource Settings 2024;12:12319] Non -co mmerc ial us e o nly However, successful treatment outcomes are far from certain because 68.5% of IVF cycles do not result in a live birth. These high failure rates lead many couples to look for ways to improve their chances of achieving conception.5 CAM includes diagnostic, therapeutic, and preventive methods that complement convention- al treatments. Convenient access and lower costs of such treat- ments have increased their application in different populations.4 The various types of CAM offered, along with the increasing mar- ket for alternative fertility products, make it significant to have a broader understanding of the effectiveness of these treatments. CAM supposedly offers couples a way to improve outcomes and/or decrease stress and anxiety levels during treatment. CAM is also used to incorporate cultural traditions of health and fertility as well as increase feelings of hope and control during a biomedical fertility treatment plan. Some patients also use CAM as an alterna- tive to ARTs, although most fertility patients use CAM in addition to biomedical fertility treatment.5 Justification The findings of this study will redound to the benefit of both healthcare providers and infertile women and will uncover critical areas in Sudanese culture. We could not find any study in Sudan that explored the use of CAM for the treatment of infertility. However, various complementary therapies, including spiritual and herbal methods, are well known among the community in Sudan. Statement of the problem Infertility is a public health issue. The stigma, costs, and uncer- tainty associated with biomedical fertility treatments often entice those who have problems conceiving to use CAM.6 Despite the popularity of traditional and complementary medicine, evidence of its safety and efficacy remains inconclusive.7 In Sudan, the success rate of ARTs claimed by fertility centers is between 25-30%, which is low. Currently, there are two significant barriers to infertility care mentioned by all centers: high cost and inaccessibility. Moreover, the average Sudanese couple cannot afford ARTs with- out support.8 A large sector of the Sudanese population uses tradi- tional and religious medicine to meet their primary healthcare needs. In addition to being accessible and affordable, it is part of their belief system. Despite reported and unreported complications in traditional practice, people seek traditional healers regularly and confide in them; they respect them and hold them in high regard.9 The literature shows widespread use of CAM among infertile women. Studies indicated that 49.6% of women in Iran, and 36.5% in Sierra Leone used herbal medicine for infertility treatment.11,19 Despite the widespread use of CAM, only 8% and 3% of users reported discussing the issue with their doctors, educators or nurs- es, respectively.10 In the current study, the researchers propose to investigate the use of CAM and its determinant factors among Sudanese infertile women. Aims and objectives As previously mentioned, the general objective is to study CAM utilization and its determinant factors among Sudanese infertile women attending governmental fertility clinics in Khartoum state in 2020. The specific objectives include: i) to measure the percentage of infertile women attending fertility centers who use CAM; ii) to identify the types of CAM methods used for fertility enhancement; iii) to identify infertile women’s perception of the effect of CAM on their health status. Materials and Methods Study design and setting This study has an exploratory cross-sectional descriptive, clin- ic-based design. It was conducted at five randomly selected fertil- ity centers in Khartoum state, Sudan (Elneel Fertility Center, Maternal Health, Gynecology, Obstetrics and IVF Center, Royal Care Hospital, Elsir Abulhassan Fertility Center, Saad Abulela Hospital) from March to December 2020. Study population The study population included infertile females who attended a fertility center at the time of the study. The inclusion criteria were being Sudanese and a female of reproductive age, with primary or secondary infertility. Sample technique and sample size Study participants were selected using the convenient sam- pling method. In order to estimate the sample size, Equation 1 was used: 𝑛 = 𝑧2 ×p (1 − 𝑝) [Eq. 1] 𝑑2 where n is the desired sample size and z is the standard normal deviation of 1.96 at a 95% confidence interval. In order to estimate the sample size, the values of p and 1-p were considered 0.5. The value of d was 0.05 at a confidence level of 99% and z-score was 1.95. Based on Equation 1, the estimated sample size was 240. In addition, considering the probability of dropouts, 20 extra partici- pants were added. Data collection method A structured face-to-face interview using a questionnaire was done by trained survey team members; their training included methods of asking the questions, providing an appropriate expla- nation about the types of CAM modalities available, and docu- menting the answers based on the questionnaire. Data collection tool For gathering information, a researcher-made questionnaire based on the literature, previous research, and the researcher’s knowledge and experience was used. The questionnaire consists of three parts: i) Demographic data form (including age, education, occupation, income, living place, having other chronic diseases, marital history, infertility history, infertility cause, infertility treat- ment, and having children); ii) Data related to infertility; iii) Data related to CAM (herbs, folklore, and spiritual healings). Data analysis Statistical Package for the Social Sciences (SPSS) (IBM, Armonk, NY, USA) was employed for data analysis. Frequencies for each variable were generated and organized into tables using SPSS. A chi-square test was used to determine the association between the independent variables and demographic characteris- tics; p≤0.05 was considered statistically significant. Ethical considerations Ethical approval from the Khartoum Faculty of Nursing University Sciences Institutional Review Board was obtained. Informed consent from each research candidate was obtained, and confidentiality was kept. Article [Healthcare in Low-resource Settings 2024;12:12319] [page 363] Non -co mmerc ial us e o nly Results Demographic and disease characteristics The current study is an investigation of Sudanese women, use of CAM for infertility treatment. Sudan is a well-known country for its population heterogeneity. Different tribes are well-mixed in the Sudanese community. This indeed ensures the versatility of the study place. In total, 264 infertile women were invited to participate in the study from 4 different infertility centers in Khartoum State, Sudan. Of these, 253 (95.8%) agreed to participate; they all completed the questionnaire. The mean age of participants was 31.59±6.9 years (range 17-50 years) (Table 1). When the educational status was examined, it was found that most of the women were graduates (53.8%) and secondary school graduates (26.9%); additionally, 73.1% of the participants lived in urban areas whereas the rest lived in rural as well as suburban areas (3.8% and 23.1%, respectively). The majority of the participants (54.5%) were diagnosed with primary infertility, whereas the rest of them (115, 45.5%) were diagnosed with secondary infertility. The etiologies of infertility were as follows: female infertility for 111 (43.9%) participants, male infertility for 22 (8.7%), combined infertility for 29 (11.5%), and unexplained or unknown infertility for 91 (36.0%). Moreover, the length of infertility was 5±4.2 years. The sociodemographic and reproductive characteristics of the study participants are detailed in Tables 1 and 2. Complementary and alternative medicine use Results showed that of the 253 participants, 51.4% reported that they had used complementary therapies for the treatment of infertility. Approximately 90% of them revealed that their reason for using such treatments was for the treatment of infertility; mean- while, other reasons were to promote health and decrease stress (12.9% and 2.3%, respectively). Based on the results, among CAM, herbal treatments were the most prevalent (Table 3): fenugreek (26.9%), followed by argell (20.2%), gingergrass, and cinnamon (19% for each). The rest of the practices are spiritual healing, represented in Roquia (Quran) at 6.7% and Faki’s help at 4.7%. Folkloric practices are shown in Table 4. As regards the perception of CAM among women who used it for infertility treatment, virtually 60% of them agreed that complementary medicines are safe for their health, while almost 40% think that herbal medicines are effective for treating infertili- ty. About 80% of participants did not disclose to their healthcare provider that they were using CAM. 70% of them used CAM due to a recommendation by family, about 46% by friends, whereas 10% based on a suggestion from their healthcare providers (doc- tors, nurses, and pharmacists). A logistic regression model was constructed to assess associa- tions between independent factors and complementary manage- ment. Demographic, reproductive, and complementary medicine- use characteristics were incorporated into the model. In the multi- variate linear regression analysis, following adjustment for other variables, residence and length of infertility were observed to have Article Table 1. Demographic data of the participants (n=253). Variable Total (%) T & CAM users (%) T & CAM non-users (%) Age, years Mean 31.59 32.2±6.8 30.9 Standard deviation 6.900 6.8 7 Minimum 17 17 18 Maximum 50 50 50 Education Basic 18 (7.1) 8 (6.2) 10 (8.1) Secondary 57 (22.5) 35(26.9) 22 (17.9) Graduate 137 (54.2) 70(53.8) 67 (54.5) Postgraduate 30 (11.9) 12(9.2) 18 (14.6) Uneducated 11 (4.3) 5(3.8) 6 (4.9) Religion Islam 249 (98.4) 130 (100) 119 (96.7) Christian 3 (1.2) 0 (0) 3 (2.4) Other 1 (0.4) 0 (0) 1 (0.8) Residence area Rural 13 (5.1) 5 (3.8) 8 (6.5) Urban 198 (78.3) 95 (73.1) 103 (83.7) Suburban 42 (16.6) 30 (23.1) 12 (9.8) Residence state North 26 (10.3) 14 (10.8) 12 (9.8) South 9 (3.6) 4 (3.1) 5 (4.1) East 20 (7.9) 13 (10.0) 7 (5.7) West 13 (5.1) 6 (4.6) 7 (5.7) Middle 184 (72.7) 93 (71.5) 91 (74.0) Origin North 100 (39.5) 51 (39.2) 49 (39.8) South 10 (4.0) 5 (3.8) 5 (4.1) East 21 (8.3) 16 (12.3) 5 (4.1) West 33 (13.0) 17 (13.1) 16 (13.0) Middle 89 (35.2) 41 (31.5) 48 (39.0) [page 364] [Healthcare in Low-resource Settings 2024;12:12319] Non -co mmerc ial us e o nly an independent positive association; age, cause of infertility, and type of infertility did not have an impact on the decision to use CAM; no other significant associations were observed. Discussion The study found that nearly half (52.2%) of infertile women utilized CAM alongside conventional medical treatments. Various studies have reported different frequencies of CAM usage among infertile individuals. Comparing our findings to those of Dehghan et al.11 conducted in Iran, we observed a usage rate of 49.6%. This corresponds closely with the results of studies by Özkan et al 12. and Bardaweel et al. 13, which reported CAM usage rates of 50% and 44.7% among infertile individuals, respectively. Conversely, higher consumption of complementary treatments (76.2%) was noted in studies from Uganda14 and Turkey15. Nevertheless, some studies reported lower percentages of CAM use, such as 41% in Lebanon16 and 36.5% in Sierra Leone19. Fata et al. reported the lowest frequencies, with only 35.8% of infertile couples using CAM17. Such disagreement might be due to sociocultural and eco- nomic differences between countries, public recognition, easy access to such treatments, and the degree of cultural pressure to have children; nonetheless, according to this study, Sudanese women remain among those who consume a considerable amount of CAM, comparable to other studies. This may be due to the stig- ma, costs, and uncertainty associated with ARTs,12 which are valid in most African countries where CAM is one of the primary sources of healthcare because of its cultural and historical influ- ences.8 The significant sociodemographic variables associated with complementary and alternative treatment (CMT) use in the present study were the length of infertility (p=0.002), alongside the resi- dence (p=0.002) whether urban or rural, A woman living in a rural area is more likely to use CAM, this is valid, especially in Sudan, where the rural society, family members, and surroundings exert great pressure on the couple to have a child; moreover, the woman’s most, and sometimes sole role, is to rear children. The study did not find any relationship between education levels and using CAM, which is similar to a study done in Turkey.18 Other sociodemographic characteristics were not statistically significant in contrast to other studies conducted in Uganda and Turkey,12,14 which found education and age may influence the decision to use CAM. The study showed that women cited family and friends (72.1% and 45.9%, respectively) as key influencers in their deci- sion to use herbal medicine; this is similar to a study conducted in Sierra Leone and Jordan.21,19 Based on the results, among CAM, herbal treatments were the most prevalent: fenugreek (26.9%), fol- lowed by argell (20.2%), gingergrass and cinnamon (19% for each). This is similar to a study done in Jordan which found that 30% use herbs. Generally, the common belief in herb safety is largely attributed to an obvious misconception based on the fact that herbs and herbal products come from ‘nature’ and are there- fore ‘naturally safe’ or ‘intrinsically harmless’ (Figure 1).13 However, the risk of adverse effects increases with the fact that the choice to use herbal medicine was greatly influenced by people with low levels of knowledge about the safety and efficacy of herbal remedies, which is in line with findings from Lebanon and Sierra Leone.16,19 Other folkloric methods are aubergine fruits, cumin seeds, and dates kept under the bed (4.7%), cupping (2.0%) Article Table 2. Obstetric and gynecologic information of the infertile women (n=253). Variable All participants (%) T & CAM users (%) T & CAM non-users (%) Length of marriage Mean 6.91 7.74 6.03 Standard deviation 5.009 5.351 4.475 Minimum 1 1 1 Maximum 25 25 25 Length of infertility Mean 5.05 5.86 4.18 Standard deviation 4.257 4.977 3.126 Minimum 1 1 1 Maximum 30 30 15 Type of infertility Primary 138 (54.5) (56.9) Secondary 115 (45.5) (43.1) Cause of infertility Male 22 (8.7) 12 (9.2) Female 111 (43.9) 59 (45.4) Both 29 (11.5) 16 (12.3) Unknown or undiagnosed 91 (36.0) 43 (33.1) Used CAM for infertility Yes 130 (51.4) - - No 123 (48.6) - - Reported taking CAM to care providers Yes 32 (12.6) - - No 221 (87.4) - - Recommending others to use CAM (attitude) Yes 99 (39.1) No 153 (60.5) [Healthcare in Low-resource Settings 2024;12:12319] [page 365] Non -co mmerc ial us e o nly music therapy (1.6%), and pieces of coin or qarad worn (1.2%). Spiritual methods were also used (Faki’s help, 4.7%; Roquia, 6.7%). Figure 2 illustrates that both psychological and physiologi- cal benefits were anticipated among women from traditional prac- tices, such as achieving conception and reducing stress. These findings align with prior literature 11,17 In this study, it is apparent that there was a low disclosure rate of herbal medicine use among users; nearly 80% of CAM users reported that they did not tell their healthcare provider about taking CAM. This is comparable to studies in Uganda and Sierra Leone.14,19 The reasons for nondisclosure were that healthcare providers failed to ask and the thought that it was not necessary to divulge such information, which resonates with the current litera- ture on the nature of physician-patient communication regarding herbal medicine use in Africa.20 Other reasons for nondisclosure cited in the literature included fear of health providers’ reactions that can potentially undermine care and perceived lack of support and understanding from conventional healthcare providers. Effective communication between patients and providers is essen- tial to achieving the desired goal of infertility care, the absence of which can negatively affect patients’ treatment outcomes.19 Therefore, healthcare providers should be aware of this and initiate a discussion with their patients about the use of alternative medical care, ensuring it is free from prejudice and based on mutual respect. As regards the perception of herbal medicine use among women seeking care for infertility, about half of the participants reported using CAM for the reason that it is safe as well as effec- tive. This is similar to that observed in the literature.11,16,19 Article Table 3. The herbal methods used by the study participants (n=253). Method % Fenugreek 26.9 Argell 20.2 Ginger grass 19 Cinnamon 19 Common sage 11.9 Sesame 10.7 Marjoram 10.7 Aashab 9.9 Honey and its products 9.1 Arabic gum 7.1 Mint 4.7 Clove 4.7 Black seed 4.7 Costus 4 Nutritional advice 2.8 Mugworts 2.4 Olive oil 2 Dates 2 Cress 2 Liquor ice 1.6 Kef maryam 1.6 Ginger 1.6 Binali herbs 1.6 Vitamins supplements 1.2 Alum 1.2 Indian almond 0.8 Fennel 0.4 Corton seed 0.4 Table 4. Folkloric methods and spiritual methods used by infertile women (n=253). Folkloric methods % Aubergine fruits, cumin seeds and dates kept under the bed 4.7 Cupping 2.0 Music therapy 1.6 Pieces of coin or Qarad worn 1.2 Spiritual methods % Faki’s help 4.7 Roquia 6.7 Figure 1. Factors leading to the usage of complementary and alter- native medicine by infertile women (n=253). Figure 2. Reason for using complementary and alternative medi- cine by infertile women (n=253). [page 366] [Healthcare in Low-resource Settings 2024;12:12319] Non -co mmerc ial us e o nly Conclusions In conclusion, CAM use among infertile women seeking med- ical assistance for their infertility condition was common, and herbal treatments were the most prevalent type. The most impor- tant factor affecting the satisfaction of infertile individuals with CAM was their belief in the safety of such treatments. Healthcare providers providing fertility care should be attentive to the health- seeking behavior of patients under their care and initiate dialogue with patients on their risks and benefits. Recommendations Further studies, intended to identify the benefits or harm to patients seeking infertility treatment, are required. Intensive hor- monal treatment and exposure to anesthetic agents might potential- ly interact with some CMT. Study strengths and limitations The major limitation of this study was the sample frame, which included women from one state in Sudan. Moreover, it was con- ducted in fertility clinics; due to budget and time constraints, this may underestimate the actual utilization rate, as there is potential bias. As a consequence, further studies should be conducted in society. Nevertheless, this study presents the first empirical evi- dence of CAM use among women seeking infertility care in Sudan; furthermore, it will help provide the basis for further stud- ies to be conducted. References 1. World Health Organization. WHO global report on traditional and complementary medicine 2019. Available from: https://apps.who.int/iris/handle/10665/312342. Accessed in: July 2020. 2. World Health Organization. Traditional complementary inte- grative medicine. Available from: https://www.who.int/health- topics / t radi t ional-complementary-and- integrat ive- medicine#tab=tab_1. Accessed in: July 2020. 3. U.S. Department of Health & Human Services, National Institutes of Health. 2016 strategic plan. Exploring the science of complementary and integrative health. Available from: h t t p s : / / f i l e s . n c c i h . n i h . g o v / s 3 f s - p u b l i c / NCCIH_2016_Strategic_Plan.pdf. Accessed in: May 2020. 4. National Cancer Institute, Complementary and alternative medicine. Available from: https://www.cancer.gov/about-can- cer/treatment/cam. Accessed in: December 2020. 5. Erku DA, Basazn MA. Prevalence and correlates of comple- mentary and alternative medicine use among hypertensive patients in Gondar Town, Ethiopia. Evid Based Complement Alternat Med 2016;2016:6987636. 6. El Safi A. Traditional Sudanese medicine: a primer for health care providers, researchers, and students. Khartoum, Sudan: Azza House; 2007. 7. Kuhnert N, Karar ME. Herbal drugs from Sudan: traditional uses and phytoconstituents. Pharmacogn Rev 2017;11:83-103. 8. World Health Organization. WHO traditional medicine strate- gy: 2014-2023. 2014. Available from: https://apps.who.int/ iris/handle/10665/92455. 9. Krol M, Nap A, Michels R, et al. Health state utilities for infer- tility and subfertility. Reprod Health 2019;16:47. 10. Inhorn MC, Patrizio P. Infertility around the globe: new think- ing on gender, reproductive technologies and global move- ments in the 21st century. Hum Reprod Update 2015;21:411- 26. 11. Dehghan M, Mokhtarabadi S, Heidari FG. Complementary and alternative medicine usage and its determinant factors among Iranian infertile couples. J Complement Integr Med 2018;15: /j/jcim.2018.15.issue-2/jcim-2017-0138/jcim-2017- 0138.xml. 12. Özkan FS, Karaca A, Sarak K. Complementary and alternative medicine used by infertile women in Turkey. Afr J Reprod Health 2018;22:40-8. 13. Bardaweel SK, Shehadeh M, Suaifan GA, Kilani MVZ. Complementary and alternative medicine utilization by a sam- ple of infertile couples in Jordan for infertility treatment: clin- ics-based survey. BMC Complement Altern Med 2013;13:35. 14. Kaadaaga HF, Ajeani J, Ononge S, et al. Prevalence and factors associated with use of herbal medicine among women attend- ing an infertility clinic in Uganda. BMC Complement Altern Med 2014;14:27. 15. Edirne T, Arica SG, Gucuk S, et al. Use of complementary and alternative medicines by a sample of Turkish women for infer- tility enhancement: a descriptive study. BMC Complement Altern Med 2010;10:11. 16. Ghazeeri GS, Awwad JT, Alameddine M, et al. Prevalence and determinants of complementary and alternative medicine use among infertile patients in Lebanon: a cross sectional study. BMC Complement Altern Med 2012;12:129. 17. Fata S, Tokat MA, Bagardi N, Yilmaz B. The traditional prac- tices used by couples with fertility problems, affecting factors, expected benefits, and learning paths: the Turkey sample. Niger J Clin Pract 2019;22:806-11. 18. Smith C, Armour M, Ee C. Complementary therapies and med- icines and reproductive medicine. Semin Reprod Med 2016;34:67-73. 19. James PB, Taidy-Leigh L, Bah AJ, et al. Prevalence and corre- lates of herbal medicine use among women seeking care for infertility in Freetown, Sierra Leone. Evid Based Complement Alternat Med 2018;2018:9493807. 20. Eldib A, Tashani O. Infertility in the Middle East and North Africa region: a systematic review with meta-analysis of prevalence surveys. Libyan J Med Sci 2018;2:37-44. Article [Healthcare in Low-resource Settings 2024;12:12319] [page 367] Non -co mmerc ial us e o nly