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A Delphi Study on the Management of Female Infertility by Homeopathic
Practitioners in South Africa

A research project presented to the

Faculty of Health Sciences, University of Johannesburg,

as partial fulfilment for the Master of Health Sciences in
Complementary Medicine (Homeopathy) by

Robyn Anderson
(Student number: 216019080)

Supervisor: __ ____________ _16/09/2022____

Dr J. Pellow D. Tech Hom (UJ) Date
DECLARATION

I, Robyn Anderson, declare that this dissertation is my own, unaided work. It is being
submitted for the Master of Health Sciences in Complementary Medicine (Homeopathy)
degree at the University of Johannesburg. It has not been submitted before for any degree or
examination at any other Technikon or University.

Signature __________________________ Date __19/06/2022_______

ii
ABSTRACT
Infertility is a condition that has been classified as a public health priority because of the
effects that it is known to have on the psychological, social, physical, and economic aspects
of peoples’ lives. An individual may be diagnosed with infertility if they have been unable to
conceive after more than 12 months of regular unprotected intercourse. According to a report
released in 2015, the World Health Organization (WHO) estimated at the time that between
60 to 80 million couples worldwide struggled with infertility. Another report released in 2020
found that approximately 37% of all cases of infertility are linked to a female-related cause
alone. Complementary medicine is defined as any system of healthcare that is not fully
integrated into the conventional medical system within a country. Homeopathy is a
complementary medicine modality that is used as an alternative approach to the treatment of
female infertility. There has been no study done to date to determine homeopathic
practitioners’ approaches to the management of this condition.

The aim of this study was to determine homeopathic practitioners’ approaches to managing
female infertility in South Africa by means of the Delphi technique.

The Delphi technique was used to establish expert consensus from South African
homeopathic practitioners who are considered experts in treating female infertility. Twelve
practitioners participated in this study, however only eleven completed all three rounds. A
total of thirty-two recommendations achieved expert consensus for their usefulness in the
management of female infertility. These recommendations were classified into the following
categories: case management, homeopathic treatments, dietary recommendations, lifestyle
adjustments, health supplements, and referrals.

All participants emphasised that a thorough history taking and scheduling regular follow-up
consultations should be performed in cases of female infertility. Of the eleven participants,
nine participants stated that repertorisation and treating layer by layer are useful approaches
to adopt in case analysis. The use of nosodes, mother tinctures, gemmotherapy and
organotherapy achieved consensus, with most participants agreeing on their usefulness. All
the participants agreed that it may be beneficial if patients undergoing treatment for female
infertility increase their intake of fruits and vegetables, eliminate or reduce processed foods,
ensure adequate water intake, manage stress and get an adequate amount of sleep. Ten of the
participants noted the usefulness of a high fibre diet and the elimination or reduction of sugar

iii
and refined carbohydrates, canola oil, caffeine, and cigarette smoking. Nine of the
participants agreed on the benefit of the elimination or reduction of wheat, gluten, dairy,
alcohol, and carbonated drinks as well as eating frequently throughout the day. Regarding
health supplementation, the participants agreed on the importance of supplementation for
adrenal support, and nine of the participants agreed on the use of magnesium and
supplementation to support the liver. Most of the participants agreed on the usefulness of
referring patients with female infertility to gynaecologists, endocrinologists, acupuncturists,
reflexologists, psychologists and for ultrasound imaging.

The recommendations obtained from this study may be of use to homeopathic practitioners in
the management of female infertility, but are not sufficient to be considered clinical practice
guidelines. Further studies on these interventions may be useful to improve future patient
care.

iv
DEDICATION

This study is dedicated to Lynette Anderson, my wonderful mother, who has always been my
greatest support, inspiration, and strength.
Thank you for always believing in me and encouraging me to follow my dreams.
I would not be where I am without your unwavering love and guidance.

v
ACKNOWLEDGMENTS

To Dr Janice Pellow, thank you so much for all your patience, guidance, and support as my
supervisor in this study. I am truly grateful for all that I have learnt from you and for all the
help and encouragement you have given me.

To my family and friends, thank you for your endless encouragement and care. Your support
and love have helped me more than I can express.

To Kelvin, your patience, encouragement, love, and support have meant so much to me
throughout this process.

To my sister, Candice, you and mom have always been my greatest cheerleaders. Thank you
for always being there to support and inspire me through everything I do.

To the participants, I am deeply grateful to each of you for sharing your time and your
valuable knowledge. This study would not be possible without you.

To the wonderful people I have studied with, thank you for sharing this journey with me and
for all your care and support along the way.

To Charmaine Williamson, thank you for your help with the analysis and for your kindness.

vi
Table of Contents

Affidavit ...................................................................................................................................... i
Declaration ................................................................................................................................. ii
Abstract .....................................................................................................................................iii
Dedication .................................................................................................................................. v
Acknowledgements ................................................................................................................... vi
List of tables.............................................................................................................................. xi
List of abbreviations ................................................................................................................ xii
List of appendices ................................................................................................................... xiv
List of annexures ...................................................................................................................... xv

CHAPTER ONE: INTRODUCTION

1.1 Infertility .............................................................................................................................. 1
1.1.1 Conventional treatment of infertility .................................................................... 1
1.2 Complementary medicine .................................................................................................... 2
1.2.1 Homeopathy .......................................................................................................... 2
1.3 The Delphi technique ........................................................................................................... 2
1.4 Research background & rationale ........................................................................................ 3
1.5 Research problem................................................................................................................. 3
1.6 Research question ................................................................................................................ 4
1.7 Aims and objectives ............................................................................................................. 4
1.8 Paradigmatic perspective ..................................................................................................... 4
1.9 Definitions and key concepts ............................................................................................... 5
1.10 Research design and methodology..................................................................................... 8
1.11 Ethical considerations ........................................................................................................ 9
1.11.1 Trustworthiness ................................................................................................. 10
1.12 Possible outcomes ............................................................................................................ 10
1.13 Summary .......................................................................................................................... 10

CHAPTER TWO: RESEARCH METHODOLOGY

2.1 Sample, sampling method and recruitment ........................................................................ 11
2.2 Data collection procedure ................................................................................................ 131

vii
2.3 Data analysis ...................................................................................................................... 13
2.4 Validity and reliability ....................................................................................................... 13
2.4.1 Ethics................................................................................................................. 134
2.4.2 Trustworthiness ................................................................................................. 134
2.5 Summary ............................................................................................................................ 15

CHAPTER THREE: RESULTS

3.1 Introduction ........................................................................................................................ 16
3.2 Eligibility survey................................................................................................................ 16
3.3 Round one: Delphi technique............................................................................................. 16
3.3.1 Demographic information ................................................................................. 137
3.3.2 Number of female patients with infertility seen per year.................................. 138
3.4 Approach to the management of female infertility .......................................................... 168
3.4.1 Homeopathic treatment ..................................................................................... 138
[Link] Category 1: Homeopathic approach ..................................................................... 20
[Link] Category 2: Thorough history taking ................................................................... 21
[Link] Category 3: Physical examination ........................................................................ 22
[Link] Category 4: Special investigations ....................................................................... 22
[Link] Category 5: Case analysis ..................................................................................... 25
[Link] Category 6: Multiple therapeutic interventions .................................................... 26
[Link] Category 7: Dietary adjustments .......................................................................... 33
[Link] Category 8: Lifestyle adjustments ........................................................................ 41
[Link] Category 9: Case management ............................................................................. 43
3.5 Round two: Delphi technique ............................................................................................ 46
3.5.1 Therapeutic interventions .................................................................................... 47
[Link] Nosodes ................................................................................................................ 47
[Link] Organotherapies .................................................................................................... 48
[Link] Biopuncture .......................................................................................................... 48
[Link] Organ drainage ..................................................................................................... 49
[Link] Therapeutic interventions prescribed for underlying disorders ............................ 49
3.5.2 Dietary and lifestyle modifications ..................................................................... 51
[Link] Fruits and vegetables ............................................................................................ 53
3.5.3 Supplementation.................................................................................................. 53
[Link] Supplementation for PCOS .................................................................................. 54
[Link] Supplementation for oestrogen dominance .......................................................... 56

viii
 3.5.4 Referrals .............................................................................................................. 57
[Link] Blood tests ............................................................................................................ 58
3.6 Round three: Delphi technique .......................................................................................... 60
3.7 Summary ............................................................................................................................ 65

CHAPTER FOUR: DISCUSSION OF RESULTS

4.1 Introduction ........................................................................................................................ 66
4.2 Overview of results ............................................................................................................ 66
4.2.1 The Delphi technique .......................................................................................... 66
4.3 The approach of homeopathic practitioners in South Africa to female Infertility ........... 167
4.3.1 Case management ............................................................................................... 67
4.3.2 Homeopathic treatment ....................................................................................... 69
[Link] Nosodes ................................................................................................................ 69
[Link] Mother tinctures .................................................................................................... 71
[Link] Gemmotherapy ..................................................................................................... 79
[Link] Organotherapy ...................................................................................................... 81
4.3.3 Dietary and lifestyle modifications ..................................................................... 83
[Link] Dietary modifications ........................................................................................... 83
[Link] Lifestyle modifications ......................................................................................... 87
4.3.4 Supplementation.................................................................................................. 88
4.3.5 Referrals .............................................................................................................. 92
4.4 Strengths and limitations.................................................................................................... 94
4.4.1 Strengths.............................................................................................................. 94
[Link] Platform of the questionnaire ............................................................................... 94
[Link] Anonymity ............................................................................................................ 94
4.4.2 Limitations .......................................................................................................... 94
[Link] Study sample ........................................................................................................ 94
[Link] Interventions in the third questionnaire ................................................................ 95
[Link] Access to recent studies ........................................................................................ 95
[Link] Security ................................................................................................................. 95
[Link] Bias ....................................................................................................................... 95
[Link] Limitations of the Delphi technique ..................................................................... 96
4.5 Summary ............................................................................................................................ 96

ix
 CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS
5.1 Introduction ........................................................................................................................ 97
5.2 Conclusion ......................................................................................................................... 97
5.3 Recommendations .............................................................................................................. 98

References ................................................................................................................................ 99

x
List of Tables
Table 3.1: Demographic information of participants ............................................................... 17
Table 3.2: Number of female infertility patients seen per year ............................................... 18
Table 3.3: Homeopathic treatment of female infertility .......................................................... 19
Table 3.4: Participants’ ratings of various therapeutic interventions ..................................... 47
Table 3.5: Participants’ ratings of dietary and lifestyle modifications ................................... 52
Table 3.6: Participants’ recommendations on supplementation ............................................. 54
Table 3.7: Participants’ recommendations on supplementation in PCOS ............................... 54
Table 3.8: Participants’ recommendations on supplementation in oestrogen dominance ....... 57
Table 3.9: Participants’ recommendations on referrals ........................................................... 57
Table 3.10: Final ratings of statements from round three ........................................................ 60

xi
List of Abbreviations
5-MTHF 5-methyltetrahydrofolate
AHPCSA Allied Health Professions Council of South Africa
ALA Alpha-lipoic acid
ALT Alanine aminotransferase
AMH Anti-Müllerian hormone
ART Assisted Reproductive Technology
AST Aspartate aminotransferase
BMI Body Mass Index
COMT Catechol-O-methyltransferase
CVD Cardiovascular Disease
CYP1A1 Cytochrome P450 family 1 subfamily A member 1
CYP17A1 Cytochrome P450 family 17 subfamily A member 1
DHT Dihydrotestosterone
DIM Diindolylmethane
DNA Deoxyribonucleic acid
EGCG Epigallocatechin gallate
ERα Oestrogen Receptor α
ERβ Oestrogen Receptor β
ESR Erythrocyte Sedimentation Rate
FBC Full Blood Count
FDA Food and Drug Administration
FOD Female orgasmic disorder
FSAD Female sexual arousal disorder
FSH Follicle-stimulating hormone
GABA Gamma-aminobutyric acid
GERD Gastroesophageal reflux disease
HSDD Hypoactive sexual desire disorder
HDC Higher Degrees Committee
HDL High-density lipoprotein
HPA Hypothalamic-pituitary-adrenal
HSA Homeopathic Association of South Africa
IBS Irritable Bowel Syndrome

xii
ICSI Intracytoplasmic sperm injection
IL-1 Interleukin-1
IL-6 Interleukin-6
IUI Intrauterine insemination
IVF In vitro fertilisation
LDL Low-density lipoprotein
LH Luteinising hormone
MCV Mean Cell Volume
NAC N-Acetyl Cysteine
NAFLD Non-alcoholic fatty liver disease
NASH Non-alcoholic steatohepatitis
NF-κB Nuclear Factor Kappa B
NQO1 NAD(P)H quinone dehydrogenase 1
OCP Oral Contraceptive Pill
OHSS Ovarian hyperstimulation syndrome
P450scc P450 side chain cleavage
PCOS Polycystic Ovarian Syndrome
PMS Premenstrual Syndrome
RCT Randomised Controlled Trial
REC Research Ethics Committee
SHBG Sex hormone binding globulin
SULT1A1 Sulfotransferase family 1A member 1
TNF-α Tumour Necrosis Factor Alpha
TCM Traditional Chinese Medicine
T3 Triiodothyronine
T4 Thyroxine
TSH Thyroid stimulating hormone
USD United States Dollars
UVB Type B ultraviolet
WHO World Health Organisation

xiii
List of Appendices
Appendix A: Information letter ............................................................................................. 149

Appendix B: Research consent form ..................................................................................... 152

Appendix C: Responses from round one ............................................................................... 154

Appendix D: Analysis of responses from round two ............................................................. 176

Appendix E: Analysis of responses from round three ........................................................... 184

Appendix F: REC clearance letter ......................................................................................... 187

Appendix G: HDC letter ........................................................................................................ 189

Appendix H: Letter from a qualitative analyst ...................................................................... 190

Appendix I: Turnitin report .................................................................................................... 191

Appendix J: Ethical clearance renewal letter ......................................................................... 192

xiv
List of Annexures
Annexure 1: Round 1 questionnaire ...................................................................................... 194
Annexure 2: Round 2 questionnaire ...................................................................................... 197
Annexure 3: Round 3 questionnaire ...................................................................................... 205

xv
CHAPTER ONE: INTRODUCTION

This chapter introduces the research study by elaborating on its background, describing the
research problem and the aim of the study, as well as the rationale behind the research
problem. The key concepts of this study will also be discussed.

1.1 Infertility
Infertility is a relatively common disorder of the reproductive system defined as an inability
to achieve a successful pregnancy after 12 months or more of regular unprotected sexual
intercourse or therapeutic insemination (Practice Committee of the American Society for
Reproductive Medicine, 2013). It is estimated that approximately 8-12% of couples of
reproductive age globally are affected by infertility (Vander Borght and Wyns, 2018). As a
result, the World Health Organisation (WHO) classifies infertility as the fifth most prevalent
serious global disability in the young population (Deshpande and Gupta, 2019). Secondary
infertility is the most common cause of infertility worldwide and is often as a consequence of
infections of the reproductive system (Vander Borght and Wyns, 2018).

1.1.1 Conventional treatment of infertility

Conventional treatment of infertility is largely dependent on the cause of the infertility and
may include medication to promote ovulation and enhance fertility, in vitro fertilisation
(IVF), intrauterine insemination (IUI) and ovarian stimulation (Koren et al., 2020; Wang et
al., 2019a). In general, conventional treatment of infertility is associated with exorbitant
costs, various side effects and is time consuming (Katz et al., 2011; Zarinara et al., 2016).
Wang et al. (2019a) reviewed ten randomised controlled trials (RCT) and concluded that
success rates are approximately 9-28% with ovarian stimulation, 11-33% with IUI, 14-47%
with IVF and 15-37% with a combination of ovarian stimulation and IUI. Another study done
by Dhillon et al. (2016) found that around 68.5% of treatments utilising in-vitro fertilisation
are unsuccessful. Conventional infertility treatment is known to involve multiple cycles of
treatment. The success rates of cycles one to five are 29.72%, 20.91%, 18.18%, 13.63% and
36.36% respectively (Zarinara et al., 2021).

1
1.2 Complementary medicine
Complementary medicine is defined as any alternative method of healthcare that is not fully
integrated into the conventional medical system within a country (Nguyen et al., 2019). In
South Africa, the term complementary medicine relates to the professions regulated by the
Allied Health Professions Council of South Africa (AHPCSA), namely homeopathy,
chiropractic, aromatherapy, ayurveda, Chinese medicine and acupuncture, naturopathy,
osteopathy, phytotherapy, Unani-Tibb and reflexology (Allied Health Professions Council of
South Africa, n.d.a). According to Miner et al. (2018), patients seek out complementary
medicine for infertility as an alternative to conventional treatment, to enhance the effects of
conventional treatment and to help with their anxiety levels throughout the treatment process.
The high costs and relatively low success rates of conventional treatment options for fertility
are what attract many people to complementary medicine, in addition to patients feeling that
alternative therapies are safer to use.

1.2.1 Homeopathy
Homeopathy is a complementary medicine modality that was founded in the late 18th century
by Dr Samuel Hahnemann. It is a healing method based on the fundamental principle of “like
cures like”; it involves prescribing remedies that create similar symptoms in a healthy person
that it would then treat in a diseased person (Viganò et al., 2015). Research related to the
effectiveness of homeopathy in treating female infertility is limited, however available
studies have suggested a potential improvement in infertility and fertility parameters using
homeopathic treatments (Lobo et al., 2018; RajachandraSekar, 2022). There are currently 582
registered homeopathic practitioners in South Africa (Allied Health Professions Council of
South Africa, n.d.b); according to their scope of practice, they are permitted to diagnose, treat
and prevent any illness or deficiency by means of homeopathic remedies, dietary advice or
dietary supplementation, prescribed in accordance with homeopathic principles (Allied
Health Professions Council of South Africa, n.d.c). There has been no study done to date to
determine homeopathic practitioners’ approaches to the management of female infertility.

1.3 The Delphi technique

The Delphi technique is a structured iterative process that gathers information in “rounds”
through a series of questionnaires completed by experts in a respective field (Boulkedid et al.,
2011). This technique allows the researcher to establish a group consensus by including
expertise from several individuals. According to Hohmann et al. (2018) expert consensus is

2
ranked lowest in the hierarchy of evidence, however, is of value in a field such as
homeopathy where there is limited research. Furthermore, the findings from Delphi studies,
allow individual practitioners to gain access to the knowledge of multiple practitioners who
are considered knowledgeable regarding a particular health problem (Musahl et al., 2019).

1.4 Research background and rationale

The Delphi technique has previously been used in the field of complementary medicine to
obtain expert consensus related to specific health problems. A Delphi study by Smith et al.
(2012) was conducted to formulate an acupuncture treatment protocol for infertile female
patients undergoing Assisted Reproductive Technology (ART) concluded that, despite the
lack of homogeneity in the data collected, it was possible to formulate a consensus regarding
specified methods of traditional Chinese acupuncture and manual acupuncture in the
treatment of this condition. Flower et al. (2007) used the Delphi technique to establish expert
consensus for the treatment of infertility caused by endometriosis, related to diagnosis, herb
selection and dosage in Chinese Herbal Medicine. Goldenberg et al. (2019) performed a
Delphi analysis on the naturopathic management of irritable bowel syndrome (IBS) which
resulted in consensus regarding general treatment, office visits, progress tracking, testing,
interventions, and resources related to the treatment of IBS. While there has been limited use
of the Delphi technique in the field of homeopathy, this research design may prove useful to
generate consensus amongst homeopathic practitioners regarding best practice in the
treatment of infertility. According to Niederberger and Spranger (2020), the Delphi technique
is useful in research related to healthcare. Based on the guidelines Delphi studies provide,
participants are given the opportunity to not only provide their knowledge, but also to access
information from other experts and sources. In addition, these guidelines are useful as a basis
for further research.

1.5 Research problem

Infertility is a prevalent condition with physical, spiritual and psychological consequences. In
addition to the detrimental effects of infertility in a woman, the inability to conceive also
affects her partner and the relationship between them (Walker and Tobler, 2021). Although
there are conventional methods of treatment available, these methods are expensive, time
consuming and have various adverse effects. The success rates of conventional treatments
vary depending on the treatment used but are all ineffective in more than half of patients
(Feng et al., 2021; Wang et al., 2019a; Zarinara et al., 2016). The homeopathic treatment of

3
female infertility has undergone little research. The studies that have been done have shown
that homeopathy is a potentially useful treatment in female infertility (Kalampokas et al.,
2014; Lobo et al., 2018; RajachandraSekar et al., 2022). No Delphi studies have been
published to date to formulate a treatment protocol for the treatment of female infertility by
homeopathic practitioners. Although there are studies on individual aspects of homeopathic
treatment in female infertility, there is little understanding on the combination of treatments
that homeopathic practitioners in South Africa use in cases of female infertility.

1.6 Research question

The research question which formed the focus of this study was:
How do South African homeopathic practitioners, who are considered experts in the field,
manage patients with female infertility in practice?

To answer this central question, the current knowledge and practices of South African
homeopathic practitioners considered experts in this field had to be explored.

1.7 Aims and objectives

The aim of this study was to determine homeopathic practitioners’ approaches to managing
female infertility in South Africa by means of the Delphi technique.

Objectives of this study included to:

• Investigate, by means of the Delphi technique, the experiences of homeopathic
practitioners in the management of female infertility;
• Determine expert consensus from homeopathic practitioners on an appropriate
management approach for this condition.

1.8 Paradigmatic perspective

The central paradigmatic perspective of this study is pragmatism. A pragmatic paradigm is
defined as research that focuses on “what works”, which has been established through
experience in practice (Brierley, 2017). There is also an aspect of a constructivist paradigm,
which is based on the idea that individuals construct their knowledge and understanding
through experience which they then reflect upon (Adom et al., 2016). The Delphi technique
was created in accordance with the pragmatic concept. This is evident in the following ways:

4
the technique can be used for mixed studies, it is affordable, and it only seeks input from
experts (Brady, 2015).

1.9 Definitions and key concepts

There are several key concepts and terms which will be used throughout this study. Their
definitions are listed below.

Acupressure: Acupressure is a non-invasive treatment method in which pressure is applied to

specific parts of the body along the meridians. These points are referred to as ‘acupoints’ (Au
et al., 2015).

Acupuncture: Acupuncture is a therapeutic system within Traditional Chinese Medicine

(TCM) in which small needles or pressure are applied to specific points on the body (Van Hal
et al., 2021).

Assisted Reproductive Technology (ART): ART is any form of oocyte manipulation outside
of the human body. In vitro fertilisation is the most common ART technique used (Choe et
al., 2022).

Chiropractic: Chiropractic is a system of complementary medicine that aims to prevent,

diagnose and treat disorders of the neuromusculoskeletal system and address the effects that
these disorders have on the rest of the body (Salehi et al., 2015).

Classical Homeopathy: A homeopathic approach in which a single remedy is selected based

on the totality of symptoms, considering physical, mental and emotional aspects of the case
(Banerjee et al., 2017).

Clinical Homeopathy: A homeopathic approach which places focus on the pathology of a

patient, rather than the totality of symptoms, and often involves the prescription of multiple
remedies (Banerjee et al., 2017).

Central Delusion: In homeopathy, a delusion is a belief that is created by unresolved painful

experiences. The core delusion is the delusion that started a sequence of other delusions,
which affect the emotional wellbeing of the patient (De Schepper, 2008).

5
Craniosacral Therapy: Craniosacral therapy involves gentle palpation of the area between
the cranium and sacrum to modify sympathetic activity, release myofascial structures and
normalise craniosacral rhythms (Haller et al., 2020).

Drainage Remedies: Homeopathic drainage remedies are remedies that manage the
detoxification of metabolic and exogenous waste from the body. These work by stimulating
the organs that naturally remove waste, including the liver, kidneys, lymphatic system, skin,
digestive system, pancreas and mucous membranes (Schofield, 2014).

Family Constellations: Family constellations is a type of group therapy which allows people
to address experiences of conflict in their family, or another social system (Konkolÿ Thege,
2021).

Gemmotherapy: Gemmotherapy is a branch of herbal therapy that uses macerated buds and
sprouts of medicinal plants in ethanol and glycerine, to produce a medicinal substance
(Donno et al. 2016).

Health Supplement: A health supplement is any substance or mixture of substances used to

restore, improve or modify health or to supplement dietary requirements (South African
Health Products Regulatory Authority, 2022).

Homeopathic Potencies: Potencies, in homeopathic terms, are the varying dilutions of

mother tinctures which are energised through succussion to create a homeopathic remedy.
The greater the potency, the higher the dilution (Suvarna, n.d.).

In Vitro Fertilisation (IVF): IVF is a type of ART in which oocytes are produced in the
ovaries, fertilisation is performed in a petri dish and then reimplanted into the uterus to
develop (Choe et al., 2022).

Iridology: Iridology is a diagnostic tool that evaluates the iris of the eye to detect possible
disorders in the body (Um et al., 2005).

Isotherapy: Isotherapy involves diluted preparations of a healthy organ, or the causative

agent of a disease, to treat the disease related to that same organ or causative agent (European

6
Coalition on Homeopathic & Anthroposophic Medicinal Products, 2015; Gwladys and Henri,
2019).

Live Blood Analysis: Also referred to as dark-field video analysis, live blood analysis is a
process that analyses unstained blood cells using a high-resolution dark field microscope.
Practitioners use this to diagnose possible nutritional abnormalities in the blood (Jones et al.,
2019).

Miasm: The founder of homeopathy, Samuel Hahnemann, believed that miasms are the
predisposition that an individual has to developing disease. He described three main miasms:
Psora, Sycosis and Syphilis (Nikumbh, 2020).

Mother Tincture: A mother tincture is a preparation of plant, animal or mineral material that
is obtained by the maceration, infusion and decoction in a hydroalcoholic solution (Boatto et
al., 2014).

Nosode: A nosode is a preparation in which diseased tissue is homeopathically prepared to

prevent and treat the disease related to the potentised tissue being prescribed (Rieder and
Robinson, 2015).

Organotherapy: Organotherapy is a method of preparing remedies in which organs and

glandular tissue are macerated and potentised into highly diluted preparations to treat disease
(New York Centre for Innovative Medicine, 2018).

Organ drainage: Also called biotherapeutic drainage, organ drainage is a method which
incorporates lifestyle changes with other treatment modalities such as phytotherapy,
organotherapy and gemmotherapy with the goal of facilitating the body’s natural channels of
eliminating toxins (Dunlap et al., 2013).

Osteopathy: Osteopathy is a holistic method of treatment that places focus on the relationship
between structure and function of the human body, assisting the body’s natural ability to heal
itself (Verhaeghe et al., 2018).

7
Reflexology: Reflexology is a therapeutic approach that applies pressure to specific points on
the hands, feet, and ears, called reflexology areas. It is performed to improve organ
dysfunction and maintain homeostasis (Dalal et al., 2014; Embong et al., 2015).

Repertorisation: Repertorisation is a method by which a homeopathic remedy is selected, by

limiting the selection to a small group of indicated remedies and then choosing the most
appropriate remedy, called the simillimum (Chattree, 2014).

Simillimum: The homeopathic simillimum is a carefully selected remedy which best matches
the totality of symptoms in each individual case (Naudé et al., 2010).

Totality of Symptoms: The founder of homeopathy, Samuel Hahnemann, believed that focus
should not be placed on single symptoms but all of the patients’ symptoms. Hahnemann
explained that the body produces a certain set of characteristic symptoms that reveal which
remedy it requires (Haubenschild, 2016).

Traditional Chinese Medicine: Traditional Chinese Medicine (TCM) is a system of therapy

that uses acupuncture, herbal medicines and dietary modifications to correct imbalances in
the body (Consentino et al., 2018). TCM considers the five elements (fire, wood, water, earth
and metal) to divide the human body into five systems. The interaction between these five
elements is used to understand the physiology of the body and treat disease (Lu et al., 2004).

1.10 Research design and methodology

A descriptive research design was used in this study. Descriptive designs place focus on
specific areas of interest to describe the distribution of variables without the use of a
comparison group or other hypotheses (Aggarwal and Ranganathan, 2019; Ranganathan,
2019). The Delphi technique is used in research when the body of knowledge in a particular
field is uncertain and studies with higher levels of evidence are unobtainable (Niederberger
and Spranger, 2020). Research in homeopathy is limited and predominantly provides
evidence of low quality. For example, a study done by Mathie et al. (2017) examined 52
homeopathic trials; when assessed for methodological quality, only three of these studies
were considered reliable with a low risk of bias. There is a paucity of good quality clinical
trials on the use of homeopathy for female infertility. The Delphi technique is an iterative
process that makes use of “rounds” of questionnaires which are completed by experts in a

8
specific field (Boulkedid et al., 2011). The first round asks broad questions to gain a general
understanding of the views of experts regarding a certain research question. The second
round is based on the answers received from the first round with the aim of clarifying
information and identifying common points reported by multiple experts. Lastly, the third
round (or more as needed) promotes decision making to gain a final consensus (Haughey,
n.d.). The methodology followed is discussed in more details in chapter two. The Delphi
technique allows the researcher to establish a group consensus by including expertise from
several individuals. One of the main advantages of this technique is that anonymity is
maintained, which reduces the risk of opinions being influenced by group dynamics
(Boulkedid et al., 2011; Donohoe et al., 2012; Hsu & Sandford, 2007). Expert consensus
ranks lowest in the hierarchy of evidence (Hohmann et al., 2018), however it is valuable in
the field of homeopathy where research is scarce. It allows individual practitioners to
understand the interventions used by more experienced practitioners and it adds to the
evidence-based medicine available in the field of homeopathy, which can then be used for
further research (Musahl et al., 2019; Niederberger and Spranger, 2020).

1.11 Ethical considerations

Participation in this study was entirely voluntary, with consent being required for each round.
Participants were informed of the details of the study through an information sheet that was
sent to them when they were invited to join the study. The researcher was available to answer
any questions the participants had. If participants wished to withdraw from the study, they
were free to do so at any time up until they submitted their questionnaire. Each participant
was assigned a unique code, which was recorded in a spreadsheet listing each code with an
email address, ensuring anonymity throughout. There was no identifying data known to the
researcher, making the study anonymous. These codes allowed feedback to be given to
participants after each round. The data linking the participant to the code, as well as any
completed questionnaires, were kept on a password-protected computer that only the
researcher had access to and will be kept for a period of five years, ensuring confidentiality.
No identifying data was published. The questionnaire was conducted electronically and there
were no hard copies available. There were no anticipated risks in this study. Participants were
given access to the results on request. The researcher was ethically required to maintain
objectivity and impartiality throughout the process, allowing experts to reach consensus
without results being influenced by the researcher’s personal opinion (Keeney et al., 2010).
Approval to conduct this study and ethical clearance was obtained from the University of

9
Johannesburg’s Faculty of Health Sciences Higher Degrees and Research Ethics Committees,
with the following clearance numbers: HDC-01-45-2021 and REC 241112-035 (Appendices
F, G and J). Ethical considerations and the principles of beneficence, non-maleficence,
autonomy, and justice pertaining to this study, are discussed in detail in chapter 2.

1.11.1 Trustworthiness
The criteria of trustworthiness are credibility, transferability, dependability, and
confirmability. Credibility refers to the plausibility of the data presented; the data needs to be
a true interpretation of the original views of the participants. Transferability is the degree to
which the results of a study can be applied in other contexts and settings. Dependability
involves evaluation, interpretation and recommendations in a study and the stability of these
aspects. Confirmability refers to the degree to which the results of a study may be confirmed
by other studies (Korstjens and Moser, 2018).

1.12 Possible outcomes

The study aimed to identify interventions and approaches used by homeopathic practitioners
found to be effective in managing female infertility, which is of value to homeopathic
practitioners. It also aimed to help identify any research gaps, allowing for further studies to
be conducted in the field.

1.13 Summary
Chapter one introduced the background on which the study was based. Other concepts that
were discussed included the research problem, aim and objectives, key concepts, ethical
considerations, and trustworthiness. The research design and methodology were briefly
discussed, and an overview of the study was provided. The next chapter provides an in-depth
description of the research methodology.

10
CHAPTER TWO: RESEARCH METHODOLOGY
This chapter will define the research sample, describe how data was collected and analysed
and elaborate on the validity and reliability of the methodology of this study.

2.1 Sample, sampling method and recruitment

At the time that this study was conducted, there were 582 registered homeopaths in South
Africa (Allied Health Professions Council of South Africa, n.d.b). For the purpose of this
study, a minimum of ten homeopathic practitioners, considered experts in the field of female
infertility and practicing in South Africa were considered a sufficient sample size to obtain
consensus. Participants were purposively sampled and invited to participate. Purposive
sampling is a method used in qualitative studies where individuals or groups who are
particularly knowledgeable in a field are selected to optimise the use of limited sources
(Palinkas et al., 2015). Potential participants were identified through leads obtained from the
homeopathic industry and the Homeopathic Association of South Africa (HSA), as well as
through snowball sampling. Snowball sampling is a method in which participants are asked to
provide a name of at least one other potential participant, who will in turn be asked to provide
at least one more name and so on (Kirchherr and Charles, 2018). This was performed by
asking homeopathic practitioners who they believe to be experts in infertility, and then
contacting the recommended practitioners to find out if they meet the inclusion criteria.
Snowball sampling is a method used when samples meeting the desired criteria of a study are
difficult to find (Naderifar et al., 2017). The contact details of practitioners were freely
available online on the HSA website.

For participation in this study, the following inclusion criteria had to be met: registration as a
homeopathic practitioner with the AHPCSA, a minimum of 5 years of experience in treating
female infertility, being in practice, and a valid email address to allow for correspondence.

2.2 Data collection procedure

Potential participants were sent an email informing them of the study, which included an
information letter (Appendix A). If they agreed to participate, a Google Forms survey was
sent to them via email to ascertain whether they met the inclusion criteria of the study.
Questions included in the eligibility survey were:
• At present, are you registered with the AHPCSA as a homeopathic practitioner?
• Are you currently practicing as a homeopathic practitioner?

11
 • Do you have experience in treating female infertility?
• If yes, how long have you been treating female infertility as a homeopath?

The criteria that had to be met are as follows:

• Currently registered with the AHPCSA as a homeopathic practitioner
• Currently practicing as a homeopathic practitioner in South Africa; and
• A minimum of five years of experience in treating female infertility as a homeopath.

Those that wished to participate were sent a web link and were required to give consent to
participate in the study (Appendix B) before being directed to the round one online
questionnaire (Google docs) (Annexure 1). The questionnaire was designed by the researcher
with the assistance of an expert in the field. Participants had the benefit of completing the
questionnaires at their own convenience. The first round consisted of both open- and closed-
ended questions, pertaining to: i) demographics of participants (age, gender, qualification/s,
years in practice, number of fertility patients seen per year); and ii) the interventions used by
the participants, through which they have found success in treating female infertility. An
email reminding participants to complete the survey was sent after two weeks. Responses
from this round were analysed using the methodology described below and used to create the
questionnaire for round two.

The second round (Annexure 2) gave participants the opportunity to rate the importance of
the items identified in round one using a Likert-type scale and to elaborate on the responses
given in the first round. The ratings of this scale were: ‘not recommended’, ‘unimportant’,
‘somewhat important’, ‘very important’ or ‘essential’.

In the third round (Annexure 3), the refined series of items were presented to the participants,
and they were then requested to rate their level of agreement once again for each intervention
on a Likert-type scale. For this round, the ratings of the scale were: ‘strongly disagree’,
‘disagree’, ‘unsure’, ‘agree’ or ‘strongly agree’. Participants were asked to give consent prior
to completion of each round, and each questionnaire took approximately 10 to 15 minutes to
complete. The study was concluded when consensus was reached, i.e. an agreement level of
75% or more amongst participants. This level of agreement has been accepted as consensus
in various Delphi studies and has been described as the threshold for broad consensus
(Giannarou and Zervas, 2014; Mason and Alamdari, 2007; Santaguida et al., 2018).

12
2.3 Data analysis
Open-ended questions from round one were analysed qualitatively with the content analysis
methodology (Hasson et al., 2000). This method is often used in qualitative analysis to
extract concise themes from a large amount of information (Erlingsson and Brysiewicz,
2017). The responses from each question in round one was arranged into themes depending
on what they related to, i.e. homeopathic approach, history taking, physical examination, case
analysis, therapeutic interventions, dietary and lifestyle adjustments, supplements, referrals
and special investigations. Participants were also colour-coded and given a unique tracking
code. These results were then tabulated.

The questionnaire for the second round was structured based on the themes identified in
round two. In this round, participants were requested to rate the importance of these themes
and to elaborate on vague responses in the first round. Responses were rated on a 5-point
Likert-type scale. The quantitative data from this round was analysed as follows: the number
of responses per rating were recorded in a table. The ratings from the Likert-type scale were
allocated scores one to five respectively and listed next to each other depending on how many
times each category scored. From this list, the median and interquartile range were calculated.
All major themes from the second round were repeated in the third round.

The third round involved only Likert-type scale ratings of items derived from rounds one and
two, and these ratings were used to calculate a level of consensus on these items. The data
was analysed in the same way as in round two, with the addition of a level of agreement
being calculated. Consensus for each statement was reached when the level of agreement was
75% or above.

2.4 Validity and reliability

The Delphi technique is a structured process that is commonly used in the healthcare field to
derive expert consensus through iteration and controlled feedback whilst maintaining
anonymity of the participants (Boulkedid et al., 2011; De Manincor et al., 2015). It is
particularly helpful in areas of limited evidence and promotes validity by giving respondents
the opportunity to reassess their initial feedback (Hsu & Sandford, 2007). The questionnaire
for round one was developed by the researcher with the assistance of an expert in the field.

13
2.4.1 Ethics
This study complied with the four pillars of clinical ethics: beneficence, non-maleficence,
autonomy, and justice. Beneficence refers to the responsibility to act for the benefit of the
individual, thereby protecting their rights and preventing harm. Non-maleficence is the
obligation to not cause pain or suffering to an individual. Autonomy refers to the right of an
individual to make their own decisions regarding their treatment. Justice refers to the fair and
appropriate treatment of individuals (Varkey, 2021).

2.4.2 Trustworthiness
The criteria that enhance trustworthiness in research include credibility, transferability,
dependability, and confirmability. Credibility refers to the degree of accuracy of the
researcher’s representation of the original responses of participants (Nowell et al., 2017).
Lincoln and Guba (1985) proposed strategies to use in qualitative studies to promote
trustworthiness. These strategies include prolonged engagement with participants, persistent
observation, triangulation, and member checking. Prolonged engagement with participants
involves investing sufficient time into engagement to allow participants to be familiar with
the study and to prevent misinformation (Korstjens and Moser, 2018). In this study,
participants had the opportunity to contact the researcher with any concerns or questions they
may have had. Persistent observation involves the identification of the most relevant elements
of the study, on which focus will be placed (Korstjens and Moser, 2018). The themes
identified from the first round of this study allowed the researcher to identify the important
elements of the study. Triangulation refers to the use of multiple sources and methods of data
collection (Korstjens and Moser, 2018). In this study, numerous journal articles, websites,
and books were used to source information and open-ended and close-ended questions were
used to gather data. Member checking involves the feedback of recorded data and
interpretations to the participants (Korstjens and Moser, 2018). This was performed in this
study by giving participants the opportunity to review and later amend their responses in the
third round.

Transferability refers to the degree to which the results of a study may be applicable to other
contexts or settings (Forero et al., 2018). Thick description is a strategy used to promote
transferability of a study. Thick description involves a detailed explanation of the process
followed in a study; it is essential that this explanation is detailed enough that readers may

14
interpret data themselves and draw conclusions (Tenny et al., 2021). This study strived to
provide a detailed description of the methodology followed and the analysis of data.

Dependability refers to the stability of the findings of a study over time. It involves the
evaluation, interpretation, and recommendations of a study (Korstjens and Moser, 2018). An
audit trail is a strategy used to promote dependability in qualitative studies. An audit trail
involves documented steps used to select participants and collect data from the study (Tenny
et al., 2021). These steps were explained in this study and the questionnaires used to collect
data are provided in Annexure 1 to 3.

Confirmability refers to the degree to which the results of a study may be corroborated in
other studies. Confirmability is often promoted using triangulation and reflexivity (Forero et
al., 2018). Reflexivity is the researcher’s reflection on their own biases or preconceptions and
the potential influence the researcher’s relationship with participants may have on the study
(Korstjens and Moser, 2018). Confirmability was promoted in this study by utilising
numerous sources and through the reflection done in the strengths and limitations section of
this study.

This study has been approved by the Research Ethics Committee (REC) (Appendices F and J)
and Higher Degrees Committee (HDC) (Appendix G). The results of this study were also
reviewed by a qualitative analyst (Appendix H). The dissertation was assessed for plagiarism
through Turnitin (Appendix I).

2.5 Summary
This chapter focused on the research sample of this study and provided a detailed report on
how the data was collected and analysed. It also discussed the trustworthiness, validity, and
reliability of the study as well as the procedures followed to meet ethical standards.

15
CHAPTER THREE: RESULTS

3.1 Introduction
In this chapter, the results of all three rounds of the Delphi study are described. The
objectives of this study were to investigate the experiences of South African homeopathic
practitioners in managing female patients with infertility, to obtain expert consensus on
recommendations for the appropriate management approach for this condition.

3.2 Eligibility survey

A total of 50 homeopathic practitioners were invited to join this study to which 16
practitioners agreed. Of these 16 potential participants, only 12 met the inclusion criteria.
These 12 participants were then invited to participate in the study.

3.3 Round one: Delphi technique

In round one, practitioners who had been invited to participate were sent a web link via email
to the online questionnaire, which had been formulated using Google Forms. They were
required to give consent before progressing to the questionnaire, by selecting the option that
they agreed to participate (Appendix B). Round one was completed online (Annexure 1) at
the convenience of the participants. The questionnaire took approximately 10 to 15 minutes
to complete. Participants were given one month to complete the questionnaire, with a
reminder email being sent after two weeks. The first round included open-ended and close-
ended questions (Annexure 1). The data from this round was then analysed both qualitatively
and quantitatively by the researcher; quantitative data was represented in percentages whilst
qualitative data was analysed by coding and categorising each theme, using the methods
described by Saldaña (2013). This was done by grouping coded responses into categories and
sub-categories (Appendix D). The responses from the first round were converted into the
statements that were used in the second round.

Round one consisted of two sections:

1. Demographics of the participant
2. The types of interventions found in practice to be useful in the management of female
infertility.

16
3.3.1 Demographic information
The demographic information that was collected in this section included the participant’s age,
sex, qualifications, and number of years in practice. This section revealed that the majority of
the participants were female (83.3%) and between the ages of 45 to 54 years (50%) (Table
3.1).

Table 3.1: Demographic information of participants

Biographic Characteristic No. of Participants Percentage (%)
Qualification Held
MTech Homeopathy 12 100
Diploma in Acupuncture 1 8.3
Bachelor of Medicine and Bachelor of
1 8.3
Surgery
Applying Functional Medicine in Clinical
1 8.3
Practice (AFMCP)
MTech Chiropractic 1 8.3
Bachelor of Science 1 8.3
Gender
Male 2 16.7
Female 10 83.3
Age
25-34 2 16.7
35-44 3 25
45-54 6 50
55-64 1 8.3
Number of Years in Practice
5-9 1 8.3
10-15 2 16.7
16-20 4 33.3
21-25 3 25
26-30 2 16.7
31-35 0 0
36-40 0 0

17
41 years or longer 0 0

3.3.2 Number of female patients with infertility seen per year

The participants were asked to estimate the number of female patients they see per year for
treatment of infertility. Results showed that female infertility is a commonly treated condition
by the homeopathic practitioners who participated in the study, with 41.7% (n=5) of
participants treating 41 or more patients per year. This data is represented in Table 3.2 below.

Table 3.2: The number of female infertility patients seen per year
Number of Patients Per Year Number of Participants Percentage of Participants (%)
1-10 2 16.7
11-20 4 33.3
21-30 1 8.3
31-40 0 0
41 or more 5 41.7

3.4 Approach to the management of female infertility

Participants were asked to describe their approach to the treatment of female infertility in
relation to homeopathic treatment, dietary and lifestyle advice, dietary supplements, and
referrals.

The results were qualitatively analysed (Appendix C) and used to create the questionnaires
use in the second and third rounds. The identified categories and subcategories are listed in
Table 3.3.

3.4.1 Homeopathic treatment

Participants were asked to describe their homeopathic approach to the management of female
infertility. They were asked to include details of their homeopathic approach and the type of
interventions that they may use. The categories and sub-categories are shown in Table 3.3
below.

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Table 3.3: Homeopathic management of female infertility
Categories Sub-categories

• Classical
[Link] Homeopathic approach
• Clinical

• Homeopathic
[Link] Thorough history taking
• Biomedical

[Link] Physical examination • Body language

• Blood tests
• Urine tests
• Stool tests
• Gene profiling
[Link] Special Investigations • Biores electroacupuncture device
• Live blood analysis
• Iridology
• Ultrasound
• Gynaecological assessment

• Repertorisation
[Link] Case analysis
• Treating layer by layer

• Homeopathic
o Nosodes
o Mother tinctures
• Gemmotherapy
• Organ drainage
[Link] Multiple therapeutic
• Organotherapy
interventions
• Isotherapy
• Acupuncture and acupressure
• Herbal remedies
• Health supplements
• Biopuncture

19
 • Food
[Link] Dietary adjustments
• Drinks

• Sleep
• Stress management
• Relationships
[Link] Lifestyle adjustments
• Personal hygiene
• Exercise
• Addictive substances

• Regular follow-up consultations

• Duration of treatment
[Link] Case management • Environmental factors
• Medication
• Referrals

[Link] Category 1: Homeopathic approach

Homeopathic prescribing comprises of two main styles of treatment: classical and clinical
prescribing. Various participants stated which style they have found to be useful in the
treatment of female infertility.

• Classical approach
Some participants felt that it was important to adopt the classical homeopathic approach
when treating female infertility. Classical homeopathy refers to the method in which a single
remedy is carefully chosen to address all symptoms, including physical, mental and
emotional symptoms (Banerjee et al., 2017).

“Selecting the patient’s simillimum remedy” (P3)

“Classical Homeopathic medicines” (P4)

“… a single remedy” (P6)

“Constitutional remedy…” (P7)

20
 • Clinical approach
Certain participants expressed the usefulness of the clinical homeopathic approach in treating
female infertility. The clinical approach refers to treatment which places focuses on the
pathology present, instead of the full symptom picture, and often involves the prescription of
multiple remedies or complexes at once (Banerjee et al., 2017).

“Complexes made up specifically for the patient” (P1)

“I definitely follow a more clinical approach” (P5)

[Link] Category 2: Thorough history taking

Taking a thorough history when treating female infertility was recommended by multiple
participants.

“Patients undergo a thorough case history” (P6)

• Homeopathic
Homeopathic case taking involves in-depth questioning on presenting symptoms, personal
and family medical history, physical examination and aspects related to selecting a
simillimum. The case-taking process is considered an essential part of the treatment process
due to its psychotherapeutic benefits (Prousky, 2018).

Participants mentioned that thorough case taking is necessary to identify the following:
o “The central delusion” (P2): in homeopathic treatment, a delusion is a belief that
forms over time as a result of unresolved painful experiences. The central delusion is
the initial delusion that preceded other delusions, affecting the emotions of the patient
(De Schepper, 2008).
o “Past traumatic experiences” (P2)
o “Totality of symptoms” (P2): The full set of symptoms created by a condition.
Hahnemann believed that focus should be placed on the full symptom picture, instead
of a single symptom (Haubenschild, 2016).
o “Miasm” (P2): a miasm is the main obstacle to cure in patients with chronic diseases.
One of the miasms, psora, is considered the underlying cause of all disease (Teixeira,
2019).
o “In depth homeopathic interview on mental, emotional and physical level” (P2)

21
 • Biomedical
Comprehensive history taking is an essential part of care, as it allows the practitioner to
identify aspects that will likely affect treatment (Nichol et al., 2021). Participants highlighted
that taking a thorough biomedical case is essential to determine:

o “The potential side effects of hormonal contraceptives” (P2)

o “The presence of intracellular bacterial, viral and parasitic infections” (P2)

[Link] Category 3: Physical examination

Physical examination is an essential part of providing a patient with an accurate diagnosis and
appropriate treatment (Asif et al., 2017).

• Body language
One participant recommended that the patient’s body language should be observed. It has
been found that both verbal and non-verbal communication is essential to patient-practitioner
interaction as it helps to understand the case on a deeper level (Vogel et al., 2018).

“Observation of body language” (P2)

[Link] Category 4: Special investigations

Special investigations have been identified as having an important role in clinical decision
making and improving treatment outcomes (Sikaris, 2017). Various special investigations
were identified by the participants.

• Blood tests
Participants highlighted the importance of blood tests in managing patients with infertility.
Blood tests are a useful tool to monitor certain aspects of homeostasis, reach a diagnosis and
formulate a treatment plan (Quinn et al., 2016). The specific blood tests that participants
noted are discussed in round two.

“Specialized blood … tests for identifying various pathogens causing infertility” (P2)

“Blood tests on day 3 and 21 of menstrual cycle (if roughly 28 day cycle)” (P3)

“Blood tests to assess endocrine dysfunction and inflammatory concerns” (P5)

22
 • Urine tests
One participant recommended urine tests to test for possible pathogenic causes of infertility.
Urine tests are routinely used in health screenings and are valuable in the clinical setting
(Givler and Givler, 2021). Chemical examination of urine identifies blood cells, protein,
glucose, bilirubin, urobilinogen, ketones, leukocytes and nitrites in the urine, which may be
suggestive of various conditions such as renal disease, infection, dehydration, diabetes
mellitus, liver dysfunction and pelvic inflammation. Microscopic analysis of blood found in
the urine may identify microorganisms, cell casts, cells and crystals, which also identify
various conditions such as renal disease, nephritis, viral infection and inflammation
(Queremel Milani and Jialal, 2021).

“Specialized … urine … tests for identifying various pathogens causing infertility”

(P2)

• Stool tests
One participant advised that stool tests are used to identify a possible pathogenic cause of
infertility. Stool tests are often used to diagnose and monitor treatment of disorders of the
gastrointestinal system. Analysis of stool may identify pathogens, blood, leukocytes,
pancreatic enzymes, calprotectin, alpha-1 antitrypsin, fat and sugars present in the stool
(Kasırga, 2019).

“Specialized … stool tests for identifying various pathogens causing infertility” (P2)

• Gene profiling
Genetic testing is used to screen and diagnose disorders of genetic origin, and to monitor
treatment and avoid adverse side effects (Franceschini et al., 2018). One participant
recommended that gene profiling be conducted. There are multiple genes that may be related
to female disorders: catechol-O-methyltransferase (COMT), cytochrome P450 family 1
subfamily A member 1 (CYP1A1), NAD(P)H quinone dehydrogenase 1 (NQO1),
cytochrome P450 family 17 subfamily A member 1 (CYP17A1) and sulfotransferase family
1A member 1 (SULT1A1). All these genes are related to the methylation and production of
oestrogen (GENEWAY, n.d.; Han et al., 2021; Hu et al., 2014; Kronfol et al., 2021; Qayyum
et al., 2015; Shen et al., 2013).

“If unresponsive to the initial protocol: The use of gene profiling … to map the
patient’s individual hormone metabolism pathways” (P3)

23
 • Biores electroacupuncture device
One participant recommended the Biores electroacupuncture device as a useful tool when
treating female infertility.

“Assessment on Biores electroacupuncture device” (P8)

• Live blood analysis

Live blood analysis is a procedure used by alternative medicine practitioners, where a drop of
blood is taken from a patient and analysed under a dark field microscope. It is useful to
identify various allergies and diseases such as cancer, cardiovascular disease (CVD) and
disorders of the immune system (Martel et al., 2017). Live blood analysis was identified by
one participant as a useful procedure in the management of female infertility.

“Live blood analysis” (P2)

• Iridology
Iridology was noted by one participant as a useful investigation in patients undergoing
treatment for female infertility. Iridology is a diagnostic tool that analyses the iris, noting
its colour and pattern. Iridologists can detect dysfunction in organs, psychology, or general
construction of the body by identifying certain properties in the iris (Divya et al., 2021).

“Iridology” (P2)

• Ultrasound
Ultrasound is an investigation in which the reflection of high frequency sound pulses is
used to produce an image of internal structures. It is often used as a tool for routine
screening in healthcare (Whitworth et al., 2015). Participants recommended that female
patients struggling with infertility should undergo ultrasound testing.

“Ultrasound” (P3)

• Gynaecological assessment
Participants recommended that patients with infertility undergo a thorough gynaecological
examination, hysterosalpingogram and transvaginal ultrasound. A gynaecological
examination generally involves a pelvic examination, which comprises of assessment of the
external genitalia, bimanual palpation of the uterus, vaginal speculum examination and
rectovaginal examination (Bibbins-Domingo, 2017). A hysterosalpingogram is a commonly

24
used procedure to assist in determining the cause of female infertility. Radiopaque dye is
injected into the uterus and an x-ray is done to visualise the anatomy of the uterus and
fallopian tubes (Mayer and Deedwania, 2022). A transvaginal ultrasound is a type of
ultrasound that allows close visualisation of the uterus, fallopian tubes, adnexa, and ovaries,
which would be difficult to see in an abdominal ultrasound (Nahlawi and Gari, 2021).

“Gynaecological exams for infertility check-ups” (P1)

“Hysterosalpingogram” (P3)

“Gynaecological assessment using transvaginal ultrasound for determining any

underlying factors related to infertility” (P4)

[Link] Category 5: Case analysis

After a consultation, a homeopathic practitioner must analyse the case appropriately and
decide how treatment will be approached (Eyles et al., 2011). Participants mentioned two
aspects of case analysis: repertorisation and treating layer by layer.

• Repertorisation
Repertorisation was identified by the participants as a useful tool in managing patients with
female infertility. Repertorisation is the process in which the most appropriate remedy is
chosen based on the symptoms presented. A repertory, a book or computer programme with
an index of symptoms and the remedies that fit those symptoms, is used during this process
(Bloch and Lewis, 2003).

“Repertorise which is the most appropriate remedy or remedies” (P5)

• Treating layer by layer

Treating layer by layer was identified by a participant as a useful approach when treating
female infertility. This style of homeopathic treatment was described by homeopath Dr
Francisco Eizayaga. It involves the prescription of different remedies to the patient as each
layer presents itself. Eizayaga explained that there are four different layers that need
treatment: the miasmatic, constitutional, fundamental and lesion layers (Owen
Homoeopathics, n.d.).

“Addressing gradually all existing layers right back to conception” (P2)

25
[Link] Category 6: Multiple therapeutic interventions
Participants were asked to describe the therapeutic interventions they use in treating
infertility. Interventions that were noted included nosodes, mother tinctures,
gemmotherapeutics, organ drainage, organotherapy, isotherapy, acupuncture and acupressure,
herbal complexes, health supplements and biopuncture.

• Nosodes
In this sample, one participant reported using nosodes in the treatment of female infertility. A
nosode is a therapeutic preparation made using diseased tissue to prevent or treat disease
(Rieder and Robinson, 2015).

“Prescribing nosodes… as the healing process unravels” (P2)

• Mother tinctures
Participants identified mother tinctures as a useful intervention when treating female
infertility. It should be noted that mother tinctures refer to the homeopathic preparation
described above, not herbal tinctures or extracts. A mother tincture is a therapeutic
preparation where plant material is macerated and put into a solution of alcohol and water,
usually in a dilution of 1:10, which is prepared according to methods outlined in a
homeopathic pharmacopoeia (Banerjee, 2006; Boatto et al., 2014; O’Connor, 1890;
Scheepmaker and Gower, 2011). Herbal tinctures are prepared from plant material in alcohol
prepared in varying dilutions, including 1:2, 1:5 and 1:20. These herbal tinctures are prepared
according to specific outlines described in a herbal pharmacopoeia (Romm et al., 2010).

“Rosmarinus mother tincture” (P3)

“Silybum mother tincture…” (P3)

“I also use mother tinctures…” (P5)

“They will get a combination script that can include … tinctures” (P6)

“Vitex Agnus Castus mother tincture in increasing LH and progesterone levels.”

(P10)
“Herbal Agnus castus in tincture or tablet form” (P7)

26
 • Gemmotherapy
Gemmotherapy was mentioned by participants as a beneficial intervention in female
infertility. Gemmotherapy, or phytoembryotherapy, can be defined as the therapeutic
preparations of the buds, shoots, rootlets, and sap of a young plant (Raiciu, 2019).

“I also use … gemmotherapy” (P5)

“They will get a combination script that can include… gemmotherapy” (P6)

• Organ drainage
Organ drainage was mentioned by one of the participants as useful when treating female
infertility. It is a method which aims to rid the body of toxins by stimulating its natural
detoxification pathways, through lifestyle modifications and other modalities such as
phytotherapy, organotherapy and gemmotherapy (Dunlap et al., 2013).

“Organ drainage in the form of mother tinctures” (P4)

• Organotherapy
Organotherapy is an intervention identified by the participants in this study as useful in the
treatment of female infertility. Organotherapy remedies are prepared through the maceration
and potentisation of organs and glandular tissue. (New York Centre for Innovative Medicine,
2018).

“If there is clearly a dysfunction on one or more organ systems then organ remedies
… can be selected prior to the simillimum” (P4)

“I regularly use … organ remedies” (P8)

• Isotherapy
Isotherapy was mentioned as a treatment for female infertility in this round. Isotherapy is a
method of homeopathic treatment in which remedies are produced using the agent that causes
a certain disease (European Coalition on Homeopathic & Anthroposophic Medicinal
Products, 2015).

“Isotherapy” (P11)

27
 • Acupuncture and acupressure
Acupuncture does not fall under the scope of practice of homeopathic practitioners in South
Africa, however one participant is a registered acupuncturist. Acupuncture is a type of
Traditional Chinese Medicine (TCM) where thin needles are inserted into the skin to
stimulate the underlying nerves, muscles, and connective tissue with the aim of alleviating
pain and tension (Patil et al., 2016).

“I include acupuncture” (P9)

One of the participants also recommended acupressure. Acupressure is a treatment where

pressure is applied to certain points on the body using fingers and hands, to maintain energy
balance within the body (Chen and Wang, 2014).

‘Acupressure daily on the ren meridian below the navel’ (P7)

• Health supplements
Participants noted various health supplements that are useful in the treatment of female
infertility, including multivitamins, vitamin B, selenium, iodine, zinc, diindolylmethane
(DIM), ubiquinol, omega oils, N-acetyl cysteine (NAC), inositol and magnesium. Health
supplements are taken to supplement the nutritional dietary intake of vitamins and minerals.
They are taken to treat various deficiencies and prevent chronic disease (Lentjes, 2019).

Multivitamins, or multi-minerals, are supplements containing three or more

vitamins/minerals without herbs, drugs, or hormones (Fortmann et al., 2013).

“Multivitamin” (P1)

“A good multivitamin containing methylated B vitamins, selenium, iodine and zinc”

(P3)

Vitamin B plays an important role in deoxyribonucleic acid (DNA) synthesis and repair,
immune function, methylation, and metabolism (Mikkelsen and Apostolopoulos, 2018).
Folate (vitamin B9 ) plays an essential role in epigenetic modification and cell proliferation,
with its deficiency increasing the risk of congenital malformations (Cirillo et al., 2021).

“Vitamin B complex – methylated” (P1)

“Support oestrogen metabolism with methylated B Vitamins” (P3)

28
 “Folic acid” (P7)

Selenium is a trace metal that plays an essential role in enzymatic and immune function. It
should be noted that excess Selenium in the blood is potentially harmful, so supplementation
should be monitored (Nessel and Gupta, 2021; Rayman, 2020). Selenium deficiency may be
associated with female infertility and other obstetric complications (Mistry et al., 2012).

“A good multivitamin containing … selenium” (P3)

Iodine is essential for foetal neurodevelopment and the synthesis of thyroid hormones, with
the consequences of deficiency being hypothyroidism and impaired cognitive development
(Niwattisaiwong et al., 2017).

“A good multivitamin containing … iodine” (P3)

Zinc is a trace metal that plays a vital role in immune function, wound healing, cell division,
the senses of smell and taste and carbohydrate breakdown (Rabinovich and Smadi, 2021).
Zinc plays an essential role in various processes in oocyte development, female fertility, and
pregnancy (Garner et al., 2021).

“A good multivitamin containing … zinc” (P3)

DIM is a phytochemical derived from cruciferous vegetables that is commonly taken as a

supplement. It has been shown to prevent and treat cancer by inducing apoptosis in cancerous
cells, particularly in cancer of the breast, endometrium, prostate, and colon (Munakarmi et
al., 2021; Vermillion Maier et al., 2021). DIM also has oestrogenic and anti-androgenic
functions, making it a useful intervention in polycystic ovarian syndrome (PCOS) and
hyperandrogenism (Alois and Estores, 2019).

“Support oestrogen metabolism with…DIM” (P3)

Ubiquinol is a reduced form of coenzyme Q10 that has been shown to be helpful in fatigue
and improving exercise performance. It is also a useful antioxidant (Bloomer et al., 2012;
Mizuno et al., 2020). It is potentially useful in improving the likelihood of clinical pregnancy
(Florou et al., 2020).

“Coenzyme Q10/Ubiquinol” (P6)

29
Omega 3 fatty acids are commonly used as an anti-hyperlipidaemic supplement which is
useful in multiple conditions: diabetes mellitus type 2, CVD, cancer, Alzheimer’s disease,
depression, infertility, and many others (Krupa et al., 2022; Stanhiser et al., 2022). Omega 6
is also often included in omega oil supplements; however, it has been shown to have pro-
inflammatory effects (Innes and Calder, 2018).

“Omega 3” (P6)

“Omega complexes” (P7)

NAC is a compound that is traditionally used as a mucolytic but is now emerging as a

supplement that is helpful in various neurodegenerative, psychiatric, respiratory, metabolic,
gastrointestinal, reproductive, and infectious diseases (Schwalfenberg, 2021).

“N-acetyl cysteine” (P6)

Inositol is a group of chemical compounds comprised of nine stereoisomers, with myo-

inositol and D-chiro inositol being commonly prescribed for conditions related to glucose
metabolism. These types of inositol also play a role in oocyte maturation, fertilisation,
implantation, and maturation after implantation. For these reasons, inositol is commonly
prescribed to treat PCOS (Kamenov and Gateva, 2020).

“Inositol” (P6)

Magnesium is an element that is widely used in supplementation for its beneficial effects in
metabolic syndrome, hyperlipidaemia, premenstrual syndrome, migraines, depression,
preeclampsia, renal calculi, cataracts and cardiac arrythmias (Schwalfenberg and Genuis,
2017).

“Magnesium … supplements are often necessary” (P8)

The concept of using an individualised approach to supplementation to treat a specific

condition or deficiency was noted as useful by participants. The specific circumstances that
were mentioned were PCOS/insulin resistance, vitamin deficiencies, oestrogen dominance,
contraceptive effects, microbiological terrain, and metabolic type.

“The supplements that I use for each patient will be different based on what their
specific area of concern (via what their blood tests show on day 22 of their cycle). I

30
 do not believe in protocol medicine and will prescribe specifically for each case”
(P5)

Recommendations for supplements for PCOS/insulin resistance included various proprietary

health supplements and herbal formulas, cinnamon, berberine, chromium, inositol, and
omega 3.

“Nourishing of polyfollicular/PCOS pattern with Polyfem” (P3)

“PCOSITOL™ reduces LH, testosterone and insulin levels in women diagnosed

with polycystic ovarian syndrome” (P10)

“if there is insulin-resistance and PCOS then InsuMax-Q” (P11)

“If a patient has PCOS/insulin resistance, then cinnamon” (P4)

“If a patient has PCOS/insulin resistance,… berberine herbs/supplements” (P4)

“Berberine is important in insulin resistance, weight management or metabolic

syndrome hindering fertility” (P8)

“Chromium … is important in insulin resistance, weight management or metabolic

syndrome hindering fertility” (P8)

“If there is insulin-resistance and PCOS then Inositol” (code 3.1.11)

“If there is insulin-resistance and PCOS then Omega 3” (P11)

Participants recommended that patients with PCOS should be given supplements to

support the liver and adrenal glands. In round one, no details were provided on what
supplements they used specifically but these recommendations were elaborated on in
round two.

“If there is insulin-resistance and PCOS then liver support” (P11)

“If there is insulin-resistance and PCOS then adrenal support is often needed.”
(P11)

Participants also made recommendations for supplementation based on vitamin

deficiencies detected in the patient. The only deficiency that was specifically mentioned
was iron deficiency. Iron is most commonly deficient in children, premenopausal women,

31
and people in low to middle income countries. Iron deficiency anaemia is the most
common consequence of this deficiency (Pasricha et al., 2021).

“Vitamin deficiencies can be determined on blood work with the appropriate

interventions made” (P4)

“Iron may be necessary in iron deficiency anaemia” (P8)

Recommendations were made regarding supplementation in the case of oestrogen

dominance. Oestrogen dominance is the state of increased oestrogen in the blood, relative
to circulating progesterone. It is caused by an imbalanced oestrogen to progesterone rati o,
excessive production of oestrogen or impaired metabolism and excretion of oestrogen
(Kolan, 2020). Supplements that were recommended include DIM, omega 6 and a
proprietary health supplement.

“DIM (Diindolylmethane) reduces the oestrogen to progesterone ratio, as seen on

day 21 bloods, in women with oestrogen dominance” (P10)

“If menstrual irregularities or oestrogen dominance then I will use Omega 6”

(P11)

“FemiScript elevates progesterone levels in women with low LH and progesterone

levels” (P10)

Participants noted specific supplements for patients who have previously taken the oral
contraceptive pill (OCP). The OCP is the most commonly prescribed form of contraception,
but it is also used in the management of menstrual disorders. There are three types of
contraceptive pills: the extended use pill, oestrogen-progesterone pill, and progesterone only
pill (Cooper et al., 2022). Participants recommended a particular proprietary health
supplement as well as an individualised approach to supplementation.

“FemiScript reduces elevated FSH levels in women following cessation of the

OCP” (P10)

“Individualized supplements according to the metabolic type, microbiological

terrain…” (P2)

32
 • Biopuncture
Biopuncture was noted by one participant as a useful treatment in female infertility.
Biopuncture, also called biomesotherapy, is a treatment in which homeopathic preparations
are injected into specific points on the body (Ivan et al., 2013). Specific biopuncture
injections and injection sites were elaborated on in round two.

“I do biopuncture” (P12)

[Link] Category 7: Dietary adjustments

The practice of advising patients on which foods/drinks to avoid or consume is an important
part of patient management. Studies have shown that this advice improves treatment
outcomes and overall health (Tapsell, 2017). Participants made numerous recommendations
regarding dietary adjustments helpful in the management of female infertility.

• Food
The following recommendations were made by multiple participants regarding fruits and
vegetables: increase intake, use as a method of detoxification, and focus on consuming fruits
and vegetables of all colours. Aside from providing basic dietary nutrients, fruits and
vegetables have been found to reduce inflammation and potentially prevent various chronic
diseases. They are essential to a healthy diet as they contain a high nutrient density, high fibre
content and low energy density (Wallace et al., 2020). The following foods have been found
to assist in detoxification of heavy metals: malic acid (in grapes), citric acid (in citrus fruits),
succinic acid (in apples and blueberries) and citrus pectin (in the peel and pulp of citrus
fruits) (Klein and Kiat, 2014).

“Increase fruit and vegetable intake” (P4)

“Increase intake of vegetables of all colours” (P5)

“Increase plant proteins” (P9)

“1 week food detoxes with fruits and vegetables can also be indicated in certain
patients to promote detoxification through the gut prior to treatment” (P4)

“'Eating the rainbow' i.e. eating a variety of different coloured whole foods (fruits,
vegetables, proteins, unsaturated fats) at each meal improves nutrient status and
general health” (P10)

33
Another recommendation was that patients incorporate cruciferous vegetables into their diet.
Cruciferous vegetables are vegetables such as cabbage, cauliflower, Brussels sprouts, and
broccoli which contain a range of phytochemicals with numerous health benefits. These
benefits include anti-carcinogenic, oestrogen modulating and cardioprotective effects
(Blekkenhorst et al., 2020; Morrison et al., 2020; Razis and Noor, 2013; Zhang et al., 2011).

“Eat cruciferous vegetables to enhance antioxidant activity” (P5)

“Increasing cruciferous vegetable consumption to as frequently as possible reduces

symptoms of oestrogen dominance” (P10)

Participants identified the avoidance of wheat/gluten as a useful intervention in female

infertility. Gluten is the main protein in wheat, one of the most abundantly consumed grains
worldwide (Sabença et al., 2021). It is also found in barley, rye, and oats. In recent years,
wheat-avoidance diets have become more popular. Gluten has been found to potentially
contribute to obesity, diabetes mellitus type 2 and a number of allergic reactions
(Biesiekierski, 2017; Shewry and Hey, 2016).

“Cut out wheat” (P1)

“Stabilise blood sugar through limitation of refined wheat” (P3)

“Wheat products to be reduced or cut out completely especially in ladies with PCOS
or insulin resistance” (P6)

“I generally advise avoiding gluten” (P8)

Multiple participants recommended that patients eliminate sugar from their diet. Excessive
sugar intake is associated with higher incidences of obesity, diabetes mellitus type 2,
coronary heart disease and other elements of metabolic syndrome. Studies have found that
eliminating sugar from the diet reduces the prevalence of these conditions, along with
hepatocellular carcinoma, non-alcoholic steatohepatitis (NASH) and cirrhosis (Vreman et al.,
2017).

“No sugar” (P2)

“Minimizing sugar reduces blood glucose and insulin levels in women diagnosed with
polycystic ovarian syndrome” (P10)

34
Participants recommended that patients struggling with female infertility should incorporate a
moderate amount of fat into their diet. Dietary fats are necessary to provide for essential fatty
acids, fat soluble vitamins, and expendable energy. The WHO recommends that fats should
make up approximately 20-35% of total calorie intake, of which less than 10% should be
saturated fats (Liu et al., 2017).

“Medium fat” (P11)

Participants recommended a moderate intake of protein. Insufficient intake of protein causes

stunted growth, weakness, oedema, anaemia, decreased immunity, and vascular dysfunction.
Recommended daily consumption of protein is between 0.8g and 2g per kilogram of body
weight per day. However, protein intake should be adjusted according to the level of physical
activity of an individual (Wu, 2016).

“Medium protein” (P11)

Participants advised that women undergoing treatment for female infertility should try to
eliminate or reduce their intake of dairy products. There are multiple recognised risks for the
underconsumption of dairy, however there are also risks related to overconsumption – mainly
due to the added salt, sugar, and saturated fat (Comerford et al., 2021).

“I generally advise avoiding excessive dairy” (P8)

“I advise patients to cut out dairy” (P12)

Participants suggest that patients avoid prolonged periods of fasting. Research has found
potential health benefits related to consuming a larger proportion of daily calories earlier in
the day and avoiding excessive calorie intake late in the afternoon or at night (Paoli et al.,
2019). In contrast to the participants’ recommendations, studies have found that eating
breakfast, eating less frequently and avoiding snacking prevents obesity. It is recommended
that breakfast and lunch should be five to six hours apart and extending the overnight fast to
18 to 19 hours (Kahleova et al., 2019). There is little evidence that eating frequently may be
beneficial to managing female infertility. In contrast, it has been found that intermittent
fasting improves fertility in females with PCOS and hyperandrogenism (Cienfuegos et al.,
2022).

“No fasting” (P2)

35
 “Eat 3-5 meals a day” (P3)

“Avoid exceeding a 14 hour overnight fast” (P3)

Participants identified that it may be useful to advise patients to minimise their intake of
dietary carbohydrates. Diets which eliminate carbohydrates to replace them with protein or
fat have become popular in recent years with the aim of decreased mortality rates associated
with these diets (Seidelmann et al.,2018).

“Generally a low glycaemic diet is advised with no refined carbohydrates” (P8)

“Minimizing refined carbohydrates in the diet reduces blood glucose and insulin
levels in women diagnosed with polycystic ovarian syndrome” (P10)

One of the participants recommended that patients should avoid soy products when they are
being treated for female infertility. There have been concerns raised regarding the adverse
effects of soy intake however there has been little evidence to show that soy may be harmful
in human adults. The phytoestrogens present in soy can potentially decrease the risk of
developing osteoporosis, obesity, cognitive dysfunction, menopausal symptoms and cancer of
the breast, prostate, colon, and ovaries. Some data has found that soy may be harmful to
infants and should be avoided during pregnancy as it may alter the epigenome in the foetus
(Rizzo and Baroni, 2018).

“No soy” (P2)

Participants emphasised that patients struggling with female infertility should avoid non-
organic red meat. The 2015 to 2020 Dietary Guidelines for Americans recommend limiting
red meat intake to one serving per week (Johnston et al., 2019). While red meat can be a
valuable source of essential vitamins, minerals and amino acids, a high intake of red meat is
linked to the development of numerous chronic diseases such as diabetes mellitus, coronary
heart disease, stroke, heart failure and various types of cancer (Wolk, 2016).

“Exclude red meat, maximum 1 serving a week of organic, free-range red meat” (P6)

“Minimizing red meat in the diet reduces blood glucose and insulin levels in women
diagnosed with polycystic ovarian syndrome” (P10)

36
One participant highlighted that it is important to educate patients about xenoestrogens.
Xenoestrogens are compounds that mimic oestrogen that is naturally produced in the body
often causing harm. Exposure is mostly through food, either in the food itself or in its
packaging. Synthetic xenoestrogens interfere with endocrine activity and have been found to
disrupt homeostasis, alter reproductive function in males and females, increase risk of breast
cancer, abnormal growth, and impaired neurodevelopment in children (Paterni et al., 2017).

“Ensure that the patient is aware of xeno-oestrogens” (P5)

Participants recommended that patients eliminate processed foods from their diet. Processed
foods are foods that have undergone processes to make them safer for consumption, more
palatable or to preserve them. A type of processed foods, called ultra-processed foods,
contain little to no intact food, and are prepared from food derivatives (Chen et al., 2020b;
Elizabeth et al., 2020). Processed foods have been associated with the development of cancer,
CVD, diabetes mellitus type 2, irritable bowel syndrome (IBS), depression and asthma
(Elizabeth et al., 2020).

“No processed foods” (P2)

“No margarine” (P2)

One of the participants identified that eliminating vinegar from the diet may be beneficial
when treating female infertility. There are multiple types of vinegar, including rice vinegar,
balsamic vinegar, black vinegar and white wine vinegar. Vinegar has been found to have
antimicrobial, anti-diabetic, appetite stimulating, anti-obesity, anticarcinogenic and
antioxidant effects (Budak et al., 2014; Ho et al., 2017). Currently, no studies are available
regarding the harmful effects of vinegar.

“No vinegar” (P2)

One of the participants suggested that patients being treated for female infertility should not
consume canola oil. Canola oil is the oil extract of canola, a flowering plant of the
Brassicaceae family (Lin et al., 2013).

“No canola oil” (P2)

37
It was recommended by a participant that patients follow a diet high in fibre. Dietary fibre
refers to the undigestible carbohydrates, usually polysaccharides originating from plant-based
foods. Fibre is useful in decreased gut motility, constipation, weight loss, insulin resistance,
local and systemic inflammation and the prevention of colorectal cancer and depression
(Barber et al., 2020).

“Nutrient dense high fibre diet” (P3)

Another recommendation from participants is to avoid chewing gum. Chewing gum has been
associated with reducing stress, depression, high cholesterol, and hypertension (Allen and
Smith, 2015; Smith, 2013). Allen and Smith (2015) conducted a study on 100 adults who
were observed whilst chewing gum. This study concluded that chewing gum can potentially
enhance alertness and improve occupational productivity, however the mechanisms of these
effects are unclear.

“No chewing gum” (P2)

Participants promoted the elimination of inflammation-inducing foods. Inflammation has

been identified as a cause of female infertility, particularly infertility related to endometriosis
(Mohammed Rasheed and Hamid, 2020). Certain foods, particularly foods with a high
glycaemic load, have been linked to chronic inflammation in the body. Anti-inflammatory
diets eliminate pro-inflammatory foods and increase the consumption of anti-inflammatory
foods, such as omega 3 fatty acids and polyphenols (Ricker and Haas, 2017).

“Avoid inflammatory inducing foods” (P4)

One participant suggested that patients struggling with female infertility should avoid ‘junk
food’. Regular consumption of junk foods is associated with an increase in abdominal fat,
impaired glucose regulation, disorders of lipids/lipoproteins and the initiation of oxidative
stress and systemic inflammation (Bahadoran et al., 2016).

“Avoid junk foods” (P4)

One of the recommendations from participants was to avoid food allergens. A food allergy is
an immune response to the proteins in specific foods which may affect the skin,
gastrointestinal system, and respiratory system (Lopez et al., 2022). A study found that
women who have food allergies are more likely to seek treatment for infertility, however the

38
avoidance of allergens was not shown to affect chances of conception (Esfandiari et al.,
2020).

“Avoiding food allergens” (P8)

An alkaline diet was mentioned as a useful recommendation for patients struggling with
female infertility. The alkaline diet aims to produce more alkaline ions in the body by
consuming more vegetables with moderate levels of protein (Fenton and Huang, 2016). It
aims to improve bone health, prevent muscle wasting, improve cardiovascular and cognitive
health, and prevent various chronic diseases (Schwalfenberg, 2012). There is scarce research
on the effects of an alkaline diet in female fertility, however it has been found that diet is an
important factor in vaginal pH, which creates a less hospitable environment for sperm (Lin et
al., 2021).

“Alkaline diet” (P11)

• Drinks
The participants in this study made various recommendations about which drinks patients
should avoid or increase their intake of.

Participants suggested that patients have adequate water intake and avoid tap water. The
European Food Safety Authority defines adequate water intake as two litres per day in
females and two and a half litres per day in males (Nakamura et al., 2020).

“No tap water” (P2)

“Increase water consumption” (P5)

“Drink 2-3 litres of water a day” (P6)

Alcohol has been linked to more than 200 diseases, but its damage is related to how much
alcohol is consumed habitually. It has been found that even moderate intake of alcohol can
increase the risk of mortality (Iranpour and Nakhaee, 2019). Participants noted that patients
undergoing treatment for infertility should avoid alcohol consumption. Alcohol consumption
is associated with decreased fertility in women (Fan et al., 2017).

“No alcohol” (P2)

“Stabilise blood sugar through limitation of alcohol” (P3)

39
 “No alcohol” (P6)

It was noted by participants that caffeine should be limited or excluded from a patient’s diet.
Caffeine is a naturally occurring stimulant of the central nervous system, which is usually
sourced from coffee beans, but is also found in tea, energy drinks and other beverages. There
are several side effects associated with caffeine intake such as anxiety, restlessness, tremors,
increased urination, and irritability (Evans et al., 2021).

“Cut out caffeine” (P1)

“Limit/exclude caffeine” (P5)

The recommendation for coffee was to limit or eliminate it completely.

“Limit coffee to around 1-2 cups at most” (P6)

“I advise patients to cut out coffee” (P12)

Participants suggested that it may be beneficial to eliminate consuming ordinary black tea,
and to increase consumption of green tea. Black tea is a widely consumed drink prepared
from the Camellia sinensis plant (Rasheed, 2019). Green tea is also produced from Camellia
sinensis, but it differs from green tea in the processes the plant goes through in production
(Musial et al., 2020).

“No ordinary tea” (P2)

“Drink green tea twice daily” (P5)

It was recommended by participants that patients avoid using artificial sweeteners. Artificial
sweeteners are sugar alternatives which are often added to beverages, such as aspartame,
saccharin, sucralose, stevia, and acesulfame-potassium (Sharma et al., 2016).

“No artificial sweeteners” (P2)

Participants identified the usefulness in eliminating cooldrinks and energy drinks from the
diet. Sugar-sweetened cooldrinks are beverages rich in sugar and have been linked to
digestive diseases, diabetes mellitus type 2 and insulin resistance (Lana et al., 2014; Mullee
et al., 2019). Energy drinks are widely consumed beverages globally and have been found to
cause insomnia, stress, restlessness, tremors and gastrointestinal upset. These effects are

40
because of the high caffeine content, as well as other stimulants, of energy drinks (Ali et al.,
2015; Nadeem et al., 2020).

“No cooldrinks” (P2)

“No energy drinks” (P2)

[Link] Category 8: Lifestyle adjustment

Various lifestyle modifications were suggested by the participants to improve the success of
their treatment for infertility.

• Sleep
Participants mentioned that patients should get at least eight hours of sleep per night and that
they should practice “sleep hygiene”. The recommended duration of sleep for adults is seven
to nine hours per night (Hirshkowitz et al., 2015; Watson et al., 2015). Sleep hygiene is a set
of environmental and behavioural modifications that promote optimal sleep (Irish et al.,
2015).

“Increase sleep to at least 8 hours” (P1)

“Sleep hygiene” (P3)

• Stress management
Stress management appeared in the recommendations of multiple participants. The term
‘stress’ refers to any intrinsic or extrinsic stimulus that creates a bodily response (Yaribeygi
et al., 2017). Stress management includes activities that improve physical, cognitive, and
emotional wellbeing under stressful circumstances (Worthen and Cash, 2021).

“Breathing and relaxation techniques” (P3)

“Definitely stress reduction techniques” (P9)

“Stress management techniques” (P12)

• Relationships
Participants recommended that patients work to improve their sexual relationships as part of
their treatment of infertility. Dekker et al. (2020) recommends that practitioners routinely
address their patients’ sexuality because it has been found that sexuality is affected by various
physical and mental disorders. Sexual health has been defined as the social, mental, physical,

41
and emotional well-being with regard to sexuality, and not simply the absence of sexual
dysfunction (Douglas and Fenton, 2013).

“Improving sex life” (P2)

• Personal hygiene
Participants made recommendations regarding personal hygiene. These recommendations
included vaginal steaming, correct genital hygiene and the use of fluoride-free toothpaste and
non-alcoholic mouthwash.

“Vaginal steaming” (P2)

“Apply correct genital hygiene” (P2)

“Use fluoride free toothpaste” (P2)

“Use non-alcoholic mouthwash” (P2)

• Exercise
The participants noted that exercise is important in the management of female infertility.
Exercise has been shown to reduce mortality, prevent musculoskeletal and cerebrovascular
disease, prevent various types of cancers and is helpful in mental health disorders. Current
guidelines state that adults should do moderate exercise for 150 to 300 minutes per week,
with focus on muscle strengthening exercises two to three times a week (Yang, 2019).
Research shows that regular physical activity improves pregnancy rates in women with
infertility (Mena et al., 2019). Specific recommendations were made on the duration and
type of exercise that should be done.

“Exercise daily” (P7)

“Exercise (not too little, not too much) is important” (P9)

“Exercising 3-5 times a week for 30 minutes reduces stress levels, a well-known
cause of infertility” (P10)

One of the participants noted that patients should not exercise to the extreme that they
have changes in their menstrual cycles. Studies have shown that women who perform
regular intense exercise exhibit luteal phase defects, causing oligomenorrhoea, and
amenorrhoea (Cho et al., 2017).

42
 “As long as their exercise is not extreme enough to impact their cycles, they
continue” (P6)

Specific types of exercise that were mentioned included cardiovascular exercise, weight
training, yoga and pilates.

“Exercise can include cardio, weight training, yoga, pilates etc.” (P6)

• Addictive substances
Participants noted that they advise patients being treated for female infertility to avoid
cigarette smoking and recreational drugs. A study done in 2016 showed that approximately
21.5% of South African adults were cigarette smokers (Agaku et al., 2021). The most
common recreational drugs used are marijuana, cocaine, heroin, gamma-hydroxybutyrate,
gamma-butyrolactone and amphetamine (Dines et al., 2015). A population study published
in 2018 showed that of the 26 453 South Africans in the study, 4.4% of them had used
recreational drugs in the previous three months (Peltzer and Phaswana-Mafuya, 2018).

“Cut out smoking” (P1)

“No recreational drugs” (P2)

[Link] Category 9: Case management

Participants made recommendations on other aspects of case management in patients with
female infertility regarding follow-up consultations, duration of treatment, environmental
factors, and medication use.

• Follow-up consultations
Participants expressed the importance of follow-up consultations, in order to monitor
progress and adjust the treatment protocol as needed. Follow-up consultations have been
found to increase patient satisfaction and improve treatment outcomes (Brand and
Stiggelbout, 2013).

“Regular follow ups, changing the potency or the remedy as needed” (P2)

“Medicines may be changed or repeated at their follow up - roughly 3-4 weeks time”
(P6)

43
 • Duration of treatment
One participant suggested that the same treatment should be maintained for at least six
months before reviewing the prescription. No recommendations were made regarding the
exact duration of treatment for female infertility.

“Continue treatment for at least 6 months before reviewing the script” (P7)

• Environmental factors
Participants listed various recommendations regarding environmental factors that may affect
female fertility. These recommendations included the use of radiation protection devices,
natural insect repellents, insulating thatch roofs along with resolving damp/mould exposure,
regular maintenance of air-conditioners and regular pest control.

“Use radiation protection devices” (P2)

“Using natural insect repellents instead of naphthalene” (P2)

“Use insulating thatch roofs” (P2)

“Resolve any damp/mould exposure” (P2)

“Regular maintenance of all air conditioners” (P2)

“Regular pest control” (P2)

• Medication
Participants gave suggestions on medications that female patients with infertility should
avoid or use. These suggestions included avoiding hormonal contraceptives and vaccinations,
and using a herbal anthelmintic formula every three months.

“No hormonal contraceptives” (P2)

“No vaccines” (P2)

“De-worming every 3 months with herbal parasite formulae” (P2)

• Referrals
Participants noted the importance of referrals for various other treatment modalities in the
management of female infertility. These included referrals to practitioners offering
conventional infertility treatment as well as other complementary and alternative treatments.

44
Conventional treatment for female infertility usually involves three to four cycles of ovarian
stimulation and IUI, followed by IVF if IUI was unsuccessful (Penzias et al., 2020).

Intracytoplasmic sperm injection (ICSI) is a technique where a sperm cell is injected directly
into an oocyte to for fertilisation (Zheng et al., 2019). Referral to an endocrinologist for
further assessment was also mentioned by participants.

“IVF” (P1)

“ICSI” (P1)

“When necessary, I refer patients to fertility specialists for further investigations

and management. I try to maintain contact with those patients as the combined
treatment is beneficial” (P6)

“Last resort is fertility treatment should we not succeed” (P8)

“I work closely with some reproductive endocrinologists.” (P12)

Other alternative modalities that practitioners may refer their patients for include:
nutritional/dietary advice, acupuncture, chiropractic, osteopathy, TCM, craniosacral
therapy, postural integration, family constellations and reflexology.

“Nutritionist or dietician if dietary guidelines I have made are not sufficient in

getting the results we desire” (P8)

“Acupuncture - patients may have an acupuncture treatment 2-4 x a month” (P6)

“Acupuncture” (P9)

“Chiropractic” (P2)

“Osteopathy” (P2)

“Chinese medicine” (P6)

“Craniosacral therapy” (P2)

“Postural integration” (P2)

“Family constellations” (P2)

“Reflexology” (P10)

45
 “Refer to a psychologist when I can see the conception process is taking a toll on
the patient or when they have a history that may be a hinderance to them getting
pregnant. Maybe their relationship is rocky and they need therapy to assist. Trying
to conceive can be a very emotionally difficult time” (P6)

“Psychotherapy for the emotional support or stress management” (P8)

“Physiotherapy” (P2)

3.5 ROUND TWO: DELPHI TECHNIQUE

Statements from round one were used to create the second questionnaire (Annexure 2). The
second questionnaire comprised of close-ended questions, where participants rated the
importance of the interventions mentioned in round one, and open-ended questions where
participants elaborated on interventions mentioned in round one. The questionnaire was
divided into four sections: therapeutic interventions, dietary and lifestyle modifications,
supplementation, and referrals. For close-ended questions, participants rated the importance
of each intervention on a Likert-type scale. The ratings on this scale were ‘not
recommended’, ‘unimportant’, ‘somewhat important’, ‘very important’ or ‘essential’.
Participants were then given the opportunity to elaborate on specific interventions they have
found to be useful in practice. The response rate was 100% within 44 days of the
questionnaire being sent to participants.

The participants’ ratings were analysed quantitatively, where the median and interquartile
range were calculated for each statement. The median is the middle value of a set of numbers,
with half of the values above and half of the values below the median. The median is a useful
value as it is unaffected by outliers. If the median is a low number, it indicates that half of the
values are less than this value and therefore at least 50% of the values are relatively low and
the data is positively skewed. A high median indicates the opposite, and the data is negatively
skewed (Holmes et al., n.d.; Tenny and Hoffmann, 2021). The interquartile range is a value
that measures the spread of the middle values in a data set. The higher the interquartile range,
the larger the spread of data (Statology, 2021). The results of each response are shown in
Tables 3.4 to 3.9 below.

46
3.5.1 Therapeutic interventions
Numerous therapeutic interventions, taken from round one, were presented to the participants
and they were asked to rate the importance of each one. As can be seen from Table 3.4, the
median related to all statements, with the exception of organ drainage, was three or more.
This indicates that participants rated this statement as at least “somewhat important”. It can
also be seen that the only statements with an interquartile range of more than one were
repertorisation and treating layer by layer.

Table 3.4: Participants’ ratings of various therapeutic interventions

A. Therapeutic Interventions
Statements

Not recommended

Very Important

Median (IQR)
Unimportant

Important
Somewhat

Essential
Rate the importance of the following
interventions in the management of female
infertility:

Single homeopathic remedy 0 1 4 4 3 4 (1)

Homeopathic complexes 0 1 4 6 1 4 (1)
Thorough history taking 0 0 0 1 11 5 (0)
Repertorisation 0 1 5 1 5 3.5 (2)
Regular follow-ups 0 0 1 2 9 5 (1)
Treating layer by layer 0 3 2 2 5 4 (3)
Nosodes 0 4 5 1 2 3 (1)
Mother tinctures 0 2 4 5 1 3.5 (1)
Gemmotherapy 0 5 4 2 1 3 (1)
Organotherapy 0 2 8 1 1 3 (0)
Biopuncture 0 5 6 1 0 3 (1)
Organ drainage 0 6 4 2 0 2.5 (1)

[Link] Nosodes
Participants were given the opportunity to name specific nosodes and potencies they have
found to be useful in treating female infertility. The number and percentage of participants
who recommended the following nosodes for female infertility are shown below:

o Carcinosin in 200cH and 10M potencies: n=3 (25%)

47
 o Folliculinum in 30cH, 12X and 200cH potencies: n=2 (16.7%) in 30cH, 12X and
200cH
o Medorrhinum in 200cH and 10M potencies: n=2 (16.7%)
o Syphilinum: n=1 (8.3%)
o Thyroideum in 9cH and 30cH potencies: n=1 (8.3%)
o Variolinum 200cH: n=1 (8.3%)

[Link] Organotherapies
Participants were asked to provide recommendations regarding the specific organotherapies
and potencies used in the management of female infertility. The number and percentage of
participants who mentioned the following nosodes in the management of female infertility are
shown below:

o Folliculinum in 7cH and 200cH potencies: n=5 (41.7%)

o Adrenal gland: n=4 (33.3%)
o Ovary: n=3 (25%)
o Pituitary gland: n=3 (25%)
o Endometrium: n=2 (16.7%)
o Liver: n=2 (16.7%)
o Oestrogen in 4cH, 7cH and 9cH potencies: n=2 (16.7%)
o Progesterone: n=2 (16.7%)
o Thyroid: n=2 (16.7%)
o Fallopian tube: n=1 (8.3%)
o Hormeel: n=1 (8.3%)
o Ovarium compositum: n=1 (8.3%)
o Testosterone: n=1 (8.3%)
o Uterus: n=1 (8.3%)
o R20: n=1 (8.3%)

[Link] Biopuncture
Participants were asked to make recommendations on the biopuncture injections they have
found to be useful in treating female infertility. The number and percentage of participants
that recommended the following biopuncture injections are shown below:

o Ovarium compositum injected subcutaneously over the ovaries: n=3 (25%)

48
 o Thyreoidea compositum: n=2 (16.7%)
o Coenzyme compositum: n=1 (8.3%)
o Hepar compositum: n=1 (8.3%)
o Lymphomyosot: n=1 (8.3%)

[Link] Organ drainage

Participants were given the opportunity to name the organ drainage remedies they typically
use in the treatment of female infertility. The number and percentage of participants that
named the following organ drainage remedies are shown below:

o Berberis-Homaccord: n=1 (8.3%)

o Berberis vulgaris: n=1 (8.3%)
o Carduus marianus: n=1 (8.3%)
o Complex of Carduus marianus, Taraxacum officinalis and Chelidonium majus: n=1
(8.3%)
o Lymphomyosot: n=1 (8.3%)
o Nux Vomica Homaccord: n=1 (8.3%)
o Rosmarinus officinalis: n=1 (8.3%)
o Silybum marianum: n=1 (8.3%)
o Taraxacum officinalis: n=1 (8.3%)

[Link] Therapeutic interventions prescribed for underlying disorders

Participants provided information related to their choice of therapeutic interventions for
specific underlying pathologies related to female infertility.

• Female hormonal disorders

The participants were asked to provide names of the mother tinctures they have found to be
useful in managing female infertility related to hormonal disorders. The number and
percentages of participants who named mother tinctures for female hormonal disorders are
shown below:

o Vitex agnus-castus: n=11 (91.7%)

o Actaea racemosa: n=4 (33.3%)
o Angelica sinensis: n=2 (16.7%)
o Glycyrrhiza glabra: n=2 (16.7%)

49
 o Angelica archangelica: n=1 (8.3%)
o Asparagus racemosus: n=1 (8.3%)
o Calendula officinalis: n=1 (8.3%)
o Carduus marianus: n=1 (8.3%)
o Eleutherococcus senticosus: n=1 (8.3%)
o Humulus lupulus: n=1 (8.3%)
o Paeonia lactiflora: n=1 (8.3%)
o Panax ginseng: n=1 (8.3%)
o Rhodiola rosea: n=1 (8.3%)
o Thuja occidentalis: n=1 (8.3%)
o Tribulus terrestris: n=1 (8.3%)

Recommendations were given for the specific gemmotherapeutics used by participants for the
management of female infertility related to hormonal disorders. The number and percentage
of participants that made recommendations on these gemmotherapeutics are shown below:

o Rubus ideaus: n=4 (33.3%)

o Vaccinium vitis-idaea: n=2 (16.7%)
o Juniperus communis: n=1 (8.3%)
o Ribes nigrum: n=1 (8.3%)
o Tilia tomentosa: n=1 (8.3%)
o Viburnum opulus: n=1 (8.3%)

• Impaired adrenal function

Participants noted useful mother tinctures in the treatment of female infertility related to
impaired adrenal function. The number and percentage of participants that recommended
these specific mother tinctures are shown below:

o Withania somnifera: n=7 (58.3%)

o Glycyrrhiza glabra: n=6 (50%)
o Panax ginseng: n=4 (33.3%)
o Rhodiola rosea: n=4 (33.3%)
o Eleutherococcus senticosus: n=2 (16.6%)
o Passiflora incarnata: n=2 (16.6%)
o Vitex agnus-castus: n=2 (16.7%)

50
 o Cordyceps: n=1 (8.3%)
o Ginkgo biloba: n=1 (8.3%)
o Korean ginseng: n=1 (8.3%)
o Schisandra chinensis: n=1 (8.3%)
o Scutellaria lateriflora: n=1 (8.3%)
o Valeriana officinalis: n=1 (8.3%)

Specific recommendations were made for the use of gemmotherapeutics for female infertility
related to impaired adrenal function. The number and percentage of participants that
suggested these gemmotherapeutics are shown below:

o Ribes nigrum: n=4 (33.3%)

o Rubus ideaus: n=1 (8.3%)
o Tilia tomentosa: n=1 (8.3%)

• Thyroid disorders
Participants were given the opportunity to provide recommendations on mother tinctures they
have found to be beneficial in managing female infertility related to thyroid disorders. The
number and percentage of participants that made suggestions on these mother tinctures are
shown below:

o Withania somnifera: n=4 (33.3%)

o Fucus vesiculosus: n=3 (25%)
o Bacopa monnieri: n=1 (8.3%)
o Glycyrrhiza glabra: n=1 (8.3%)

Gemmotherapeutics for female infertility related to thyroid disorders were provided. The
number and percentage of participants that provided recommendations on gemmotherapeutics
are shown below:

o Rubus ideaus: n=1 (8.3%)

3.5.2 Dietary and lifestyle modifications

Participants rated the importance of various dietary and lifestyle modifications in the
management of female infertility. These ratings were then quantitatively analysed and
presented in Table 3.5. The majority of the statements have a median score of three or more,

51
except for ‘eliminating/reducing vinegar’, ‘vaginal steaming’, ‘non-alcoholic mouthwash’,
and ‘fluoride-free toothpaste’. The highest scoring statements include ‘increasing fruit and
vegetable intake’, ‘adequate water intake’, ‘elimination of cigarette smoking’, ‘adequate
sleep’, and ‘managing stress’.

Table 3.5: Participants’ ratings of dietary and lifestyle modifications

B. Dietary and Lifestyle Modifications
Statements

Somewhat Important
Not recommended

Very Important

Median (IQR)
Unimportant

Essential
Rate the importance of the following dietary
and lifestyle modifications in the management of
female infertility:

Increase fruit & vegetable intake 0 0 0 5 7 5 (1)

Eliminate/reduce wheat & gluten 0 0 5 4 3 4 (1)
Eliminate/reduce sugar & refined carbohydrates 0 0 2 5 5 4 (1)
Eliminate/reduce dairy 0 0 5 5 2 4 (1)
Eat frequently throughout the day 0 0 6 4 2 3.5 (1)
Minimise soy products 0 1 7 3 1 3 (1)
Eliminate/reduce red meat 0 2 7 2 1 3 (0)
Eliminate/reduce vinegar 0 8 3 0 1 2 (1)
Eliminate/reduce processed foods 0 0 0 8 4 4 (1)
Eliminate/reduce canola oil 0 2 3 4 3 4 (1)
High fibre diet 0 0 4 4 4 4 (2)
Adequate water intake 0 0 0 2 10 5 (0)
Eliminate alcohol 0 0 2 5 5 4 (1)
Eliminate/reduce caffeine 0 0 4 4 4 4 (2)
Eliminate carbonated drinks 0 0 2 4 6 4.5 (1)
Eliminate cigarette smoking 0 0 0 2 10 5 (0)
Adequate sleep 0 0 0 3 9 5 (1)
Manage stress 0 0 0 3 9 5 (1)
Avoid vaccinations 1 1 4 2 4 3.5 (2)
Radiation protection devices 0 2 7 1 2 3 (0)

52
Vaginal steaming 2 6 2 0 2 2 (1)
Correct genital hygiene 1 1 4 3 3 3.5 (1)
Non-alcoholic mouthwash 2 6 2 1 1 2 (1)
Fluoride-free toothpaste 2 4 5 0 1 2.5 (1)

[Link] Fruits and vegetables

Participants made various recommendations on specific aspects with regards to fruit and
vegetable intake. The number and percentage of participants who gave each recommendation
are shown below:

o Eat a range of colourful fruits and vegetables: n=3 (25%)

o Two to six portions of vegetables a day: n=3 (25%)
o Two to three portions of fruit a day: n=3 (25%)
o Cruciferous vegetables: n=2 (16.7%)
o Fruits & vegetables on the low glycaemic index list: n=2 (16.7%)
o Plant-based diet: n=2 (16.7%)
o A lot of green vegetables: n=1 (8.3%)
o Eat raw fruits and vegetables: n=1 (8.3%)
o Limit bananas and potatoes: n=1 (8.3%)
o Mostly cooked vegetables: n=1 (8.3%)

3.5.3 Supplementation
Participants were asked to rate the importance of the prescription of various supplements in
the management of female infertility. The results are presented in Table 3.6 below. All
supplements scored a median of three or more, and an interquartile range of two or less. This
means that the majority of participants agreed that each supplement was at least ‘somewhat
important’.

53
Table 3.6: Participants’ recommendations on supplementation
C. Supplementation

Statements

Somewhat Important
Not recommended

Very Important

Median (IQR)
Unimportant

Essential
Rate the importance of the following health
supplements in the management of female
infertility:

A multivitamin 0 1 6 4 1 3 (1)
Vitamin B supplement 0 0 6 3 3 3.5 (1)
Iodine supplement 2 1 9 0 0 3 (1)
Zinc supplement 0 1 10 1 0 3 (0)
Coenzyme Q10/Ubiquinol 1 0 8 3 0 3 (0)
N-Acetyl Cysteine 1 2 7 2 0 3 (1)
Magnesium supplement 0 0 5 5 2 4 (1)
Selenium supplement 1 0 6 4 1 3 (1)
Omega 3 supplement 0 0 3 5 4 4 (2)

[Link] Supplementation for PCOS

Specific recommendations were made for supplementation in female patients with infertility
related to PCOS. Participants were asked to rate the importance of each supplement. Each
supplement had a median of four or more and an interquartile range of one or less. These
values indicate that most participants rated each supplement as at least ‘very important’.
Results are shown in Table 3.7 below.

Table 3.7: Participants’ recommendations of supplementation in PCOS

Statements
Somewhat Important
Not recommended

Very Important

Median (IQR)
Unimportant

Essential

Rate the importance of the following health

supplements in the management of female
infertility related to PCOS:

Cinnamon 0 2 3 5 2 4 (1)

54
Berberine 0 0 1 8 3 4 (0)
Chromium 0 2 3 6 1 4 (1)
Inositol 0 1 0 7 4 4 (1)
Liver support 0 0 1 6 5 4 (1)
Adrenal support 0 0 1 5 6 4.5 (1)

• Liver support in PCOS

Participants were asked to provide specific recommendations on supplements that are useful
for providing support to the liver in female patients with infertility related to PCOS. The
number and percentage of participants that provided recommendations are shown below:

o Carduus marianus: n=4 (33.3%)

o CoolBlue: n=2 (16.7%)
o Diindolylmethane: n=2 (16.7%)
o Liv 52 DS: n=2 (16.7%)
o LiverScript: n=2 (16.7%)
o LivoClear: n=2 (16.7%)
o Silybum marianum: n=2 (16.7%)
o AdvaClear®: n=1 (8.3%)
o Berberine vulgaris: n=1 (8.3%)
o Boldocynara: n=1 (8.3%)
o Complex of Carduus marianus, Taraxacum officinalis and Chelidonium majus: n=1
(8.3%)
o DefenCELL®: n=1 (8.3%)
o Hepar compositum: n=1 (8.3%)
o Hormone Health: n=1 (8.3%)
o L-Glutathione: n=1 (8.3%)
o Liva: n=1 (8.3%)
o LivoTibb: n=1 (8.3%)
o Methylated vitamin B: n=1 (8.3%)
o Nux Vomica Homaccord: n=1 (8.3%)
o Rosmarinus officinalis: n=1 (8.3%)
o Sulphorophane: n=1 (8.3%)
o Taraxacum officinalis: n=1 (8.3%)

55
 • Adrenal support in PCOS
Participants were invited to provide specific recommendations for supplements they had
found to be useful to provide adrenal support in female patients with infertility associated
with PCOS. The number and percentage of participants that provided supplements are as
follows:

o Adrenocare Formula: n=2 (16.7%)

o Gamma-Aminobutyric acid: n=2 (16.7%)
o Magnesium: n=2 (16.7%)
o Magnol One: n=2 (16.7%)
o Methylated vitamin B: n=2 (16.7%)
o #1 Body: n=1 (8.3%)
o Adaptogens: n=1 (8.3%)
o Adrenal Essence®: n=1 (8.3%)
o Adrenal Support: n=1 (8.3%)
o Adrenogen®: n=1 (8.3%)
o Adreset®: n=1 (8.3%)
o Cordyceps: n=1 (8.3%)
o Cortipin: n=1 (8.3%)
o Exhilarin®: n=1 (8.3%)
o L-theanine: n=1 (8.3%)
o RE)COVER: n=1 (8.3%)
o Serenagen®: n=1 (8.3%)
o Stress-Away: n=1 (8.3%)
o Stress Damage Control ™: n=1 (8.3%)
o StressRelax powder: n=1 (8.3%)
o Vitamin B5: n=1 (8.3%)
o Withania somnifera: n=1 (8.3%)

[Link] Supplementation for oestrogen dominance

Participants rated the importance of specific supplements in the management of female
infertility related to oestrogen dominance. The results are presented in Table 3.8 below.

56
Table 3.8: Participants’ recommendations on supplementation in oestrogen dominance
Statements

Somewhat Important
Not recommended

Very Important

Median (IQR)
Unimportant

Essential
Rate the importance of the following health
supplements in the management of female
infertility related to oestrogen dominance:

Diindolylmethane (DIM) 1 0 2 3 6 4.5 (2)

Omega 6 supplement 1 4 5 2 0 3 (1)

Participants had the opportunity to list specific supplement recommendations that are
potentially beneficial in the management of female infertility related to oestrogen dominance.
The number and percentage of participants that suggested supplements are as follows:

o Sulphoraphane: n=2 (16.7%)

o Vitex agnus-castus: n=2 (16.7%)
o Diindolylmethane: n=1 (8.3%)
o Indole-3-carbinol: n=1 (8.3%)
o Lignans: n=1 (8.3%)
o Liver support: n=1 (8.3%)
o Methylated B vitamins: n=1 (8.3%)
o Renewed Balance progesterone cream: n=1 (8.3%)
o Resistant starch: n=1 (8.3%)

3.5.4 Referrals
Participants were invited to rate the importance of various referrals in the management of
female infertility. As shown in Table 3.9, the only referrals that had a median of less than
three were ‘family constellations’ and ‘iridology’. The recommendations with the highest
median were for referral to a gynaecologist and for ultrasound.

57
Table 3.9: Participants’ recommendations on referrals
D. Referrals
Statements

Somewhat Important
Not recommended

Very Important

Median (IQR)
Unimportant

Essential
Rate the importance of the following referrals in
the management of female infertility:

IVF or ICSI 2 1 3 3 3 3.5 (2)

Gynaecologist 0 0 2 4 6 4.5 (1)
Endocrinologist 1 1 4 4 2 3.5 (1)
Dietician/Nutritionist 1 0 5 4 2 3.5 (1)
Acupuncture 0 1 3 3 5 4 (2)
Chiropractic 1 2 4 2 3 3 (2)
Osteopathy 1 3 3 2 3 3 (2)
Chinese medicine 1 1 1 6 3 4 (1)
Craniosacral therapy 1 2 4 2 3 3 (2)
Family constellations 3 3 4 1 1 2.5 (2)
Reflexology 0 0 7 2 3 3 (1)
Iridology 2 4 4 0 2 2.5 (1)
Psychological care 1 0 4 3 4 4 (2)
Live blood analysis 2 6 3 0 1 2 (1)
DNA analysis 0 0 9 1 2 3 (0)
Ultrasound 0 1 1 4 6 4.5 (1)

[Link] Blood tests

Specific blood tests were suggested that were potentially helpful in the management of
female infertility. The number and percentage of participants that suggested blood tests are
shown below:

o Thyroid function and antibodies: n=8 (66.7%)

o Oestrogen/E2 : n=6 (50%)
o Vitamin D3 : n=6 (50%)
o Follicle stimulating hormone: n=5 (41.7%)

58
o Luteinising hormone: n=5 (41.7%)
o Prolactin: n=5 (41.7%)
o Dehydroepiandrosterone: n=4 (33.3%)
o Progesterone: n=4 (33.3%)
o Testosterone: n=4 (33.3%)
o Cortisol: n=3 (25%)
o Full blood count: n=3 (25%)
o High-sensitivity C-reactive protein: n=3 (25%)
o Insulin: n=3 (25%)
o Iron studies: n=3 (25%)
o Liver function test: n=3 (25%)
o Anti-mullerian hormone: n=2 (16.7%)
o Glucose: n=2 (16.7%)
o Homocysteine: n=2 (16.7%)
o Lipogram: n=2 (16.7%)
o Amylase: n=1 (8.3%)
o Androstenedione: n=1 (8.3%)
o Anti-deoxyribonuclease B: n=1 (8.3%)
o Anti-streptolysin O: n=1 (8.3%)
o Bartonella antibodies: n=1 (8.3%)
o Bilharzia antibodies: n=1 (8.3%)
o Borrelia Western Blot: n=1 (8.3%)
o Brucella antibodies: n=1 (8.3%)
o CD57 count: n=1 (8.3%)
o Chlamydia antibodies: n=1 (8.3%)
o Coxsackie B antibodies: n=1 (8.3%)
o Cytomegalovirus antibodies: n=1 (8.3%)
o D-dimer: n=1 (8.3%)
o Epstein-Barr virus antibodies: n=1 (8.3%)
o Food screen: n=1 (8.3%)
o Haemoglobin A1C: n=1 (8.3%)
o Heavy metals condensed: n=1 (8.3%)
o Hepatitis B surface antigens: n=1 (8.3%)
o Hepatitis C antibodies: n=1 (8.3%)

59
 o Herpes antibodies: n=1 (8.3%)
o H. pylori antigens: n=1 (8.3%)
o Infertility screen: n=1 (8.3%)
o Kryptopyrrols: n=1 (8.3%)
o Lipase: n=1 (8.3%)
o Lipoprotein a: n=1 (8.3%)
o Magnesium: n=1 (8.3%)
o MTHFR PCR: n=1 (8.3%)
o Mycoplasma antibodies: n=1 (8.3%)
o Q fever antibodies: n=1 (8.3%)
o Rickettsia antibodies: n=1 (8.3%)
o Sexually transmitted disease screen with or without HIV: n=1 (8.3%)
o Urate: n=1 (8.3%)
o Urea & electrolytes: n=1 (8.3%)
o Vitamin B12: n=1 (8.3%)

3.6 ROUND THREE: DELPHI TECHNIQUE

Statements from the second round were used to formulate the third questionnaire. Participants
were given the opportunity to review their responses from the previous round by rating their
agreement on a different Likert-type scale. The ratings of the scale in this round were
“strongly disagree”, “disagree”, “unsure”, “agree” and “strongly agree”. The response rate
was 91.7% (n = 11) within three months of sending out the link for round three. One
participant failed to complete the third round thus making the attrition rate of this round 8%.
The percentage of participants who rated each statement in each category was calculated, as
was the median and interquartile range. Results from the third round are presented in Table
3.10. This round was used to determine rater agreement, where a level of agreement of 75%
indicated consensus amongst practitioners. The rankings ‘agree’ and ‘strongly agree’ were
combined to calculate consensus – the number of participants that selected these rankings had
to be at least 75% of the 11 participants that completed this round. The recommendations that
achieved consensus are highlighted in yellow.

60
Table 3.10: Final ratings of statements from round three
Statements

Level of Agreement (%)

Number of Participants
Strongly disagree

Strongly agree

Median (IQR)
When treating female infertility, it is

Disagree

Unsure

Agree
important to…

A. Therapeutic Interventions
Use a single homeopathic remedy 0 3 0 5 3 72.7 (8) 4 (3)
Use homeopathic complexes 1 2 0 6 2 72.7 (8) 4 (2)
Perform thorough history taking 0 0 0 0 11 100 (11) 5 (0)
Repertorise 0 1 1 5 4 81.8 (9) 4 (1)
Schedule regular follow-Ups 0 0 0 4 7 100 (11) 5 (1)
Treat layer by layer 0 0 2 4 5 81.8 (9) 4 (1)
Use nosodes 0 1 0 5 5 90.9 (10) 4 (1)
Use mother tinctures 0 0 1 6 4 90.9 (10) 4 (1)
Use gemmotherapy 0 0 1 7 3 90.9 (10) 4 (1)
Use organotherapy 0 1 0 6 4 90.9 (10) 4 (1)
Use biopuncture 0 1 4 3 3 54.5 (6) 4 (2)
Use organ drainage 0 1 3 4 3 63.6 (7) 4 (2)
B. Dietary and Lifestyle Modifications
Increase fruit & vegetable intake 0 0 0 5 6 100 (11) 5 (1)
Eliminate/reduce wheat & gluten 0 0 2 3 6 81.8 (9) 5 (1)
Eliminate/reduce sugar & refined
0 0 1 3 7 90.9 (10) 5 (1)
carbohydrates
Eliminate/reduce dairy 0 1 1 3 6 81.8 (9) 5 (1)
Eat frequently throughout the day 0 0 2 5 4 81.8 (9) 4 (1)
Minimise soy products 0 1 2 5 3 72.7 (8) 4 (2)
Eliminate/reduce red meat 0 2 4 2 3 45.5 (5) 3 (2)
Eliminate/reduce vinegar 1 1 6 1 2 27.3 (3) 3 (1)
Eliminate/reduce processed foods 0 0 0 4 7 100 (11) 5 (1)
Eliminate/reduce canola oil 0 0 1 3 7 90.9 (10) 5 (1)

61
Consume a high fibre diet 0 0 1 5 5 90.9 (10) 4 (1)
Ensure adequate water intake 0 0 0 0 11 100 (11) 5 (0)
Eliminate alcohol 0 0 2 1 8 81.8 (9) 5 (1)
Eliminate/reduce caffeine 0 0 1 5 5 90.9 (10) 4 (1)
Eliminate carbonated drinks 0 0 2 2 7 81.8 (9) 5 (1)
Eliminate cigarette smoking 0 0 1 1 9 90.9 (10) 5 (0)
Ensure adequate sleep 0 0 0 1 10 100 (11) 5 (0)
Manage stress 0 0 0 0 11 100 (11) 5 (0)
Avoid vaccinations 0 1 2 2 6 72.7 (8) 5 (2)
Use radiation protection devices 1 1 3 2 4 54.5 (6) 4 (2)
Undergo vaginal steaming 0 1 7 2 1 27.3 (3) 4 (1)
Maintain correct genital hygiene 0 0 3 4 4 72.7 (8) 4 (2)
Use non-alcoholic mouthwash 0 1 4 4 2 54.5 (6) 4 (1)
Use fluoride-free toothpaste 1 0 4 5 1 54.5 (6) 4 (1)
C. Supplementation
Take a multivitamin 0 1 3 3 4 63.6 (7) 4 (2)
Take a vitamin B supplement 0 0 3 6 2 72.7 (8) 4 (1)
Take an iodine supplement 0 2 6 2 1 27.3 (3) 3 (1)
Take a zinc supplement 0 1 3 5 2 63.6 (7) 4 (1)
Take coenzyme Q10/Ubiquinol 0 0 5 5 1 54.5 (6) 4 (1)
Take N-Acetyl Cysteine 0 2 5 3 1 36.4 (4) 3 (1)
Take a magnesium supplement 0 1 1 4 5 81.8 (9) 4 (1)
Take a selenium supplement 0 1 2 6 2 72.7 (8) 4 (1)
Take an omega 3 supplement 0 0 3 3 5 72.7 (8) 4 (2)
Supplementation for PCOS
Take a cinnamon supplement 0 2 5 3 1 36.4 (4) 3 (1)
Take a berberine supplement 0 1 3 3 4 63.6 (7) 4 (2)
Take a chromium supplement 0 2 3 4 2 54.5 (6) 4 (1)
Take inositol 0 1 3 3 4 63.7 (7) 4 (2)
Use liver support 0 1 1 5 4 81.8 (9) 4 (1)
Use adrenal support 0 0 0 6 5 100 (11) 4 (1)
Supplementation for Oestrogen Dominance
Take diindolylmethane (DIM) 0 1 2 1 7 72.7 (8) 5 (2)

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Take an omega 6 supplement 0 7 1 1 2 27.3 (3) 2 (2)
D. Referrals
Refer for IVF or ICSI 0 3 4 3 1 36.4 (4) 3 (2)
Refer to a gynaecologist 0 0 1 4 6 90.9 (10) 5 (1)
Refer to an endocrinologist 0 0 2 7 2 81.8 (9) 4 (0)
Refer to a dietician/nutritionist 0 3 3 4 1 45.5 (5) 3 (2)
Refer for acupuncture 0 1 0 6 4 90.9 (10) 4 (1)
Refer to a chiropractor 0 3 5 2 1 27.3 (3) 3 (2)
Refer for osteopathy 0 3 4 3 1 36.4 (4) 3 (2)
Refer for Chinese medicine 0 2 2 4 3 63.7 (7) 4 (2)
Refer for craniosacral therapy 0 2 3 4 2 54.5 (6) 4 (1)
Refer for family constellations 0 3 4 3 1 36.4 (4) 3 (2)
Refer for reflexology 0 1 1 7 2 81.8 (9) 4 (0)
Refer for iridology 0 4 2 3 2 45.5 (5) 3 (2)
Refer for psychological care 0 1 0 6 4 90.9 (10) 4 (1)
Refer for live blood analysis 0 7 2 1 1 18.2 (2) 2 (1)
Refer for DNA analysis 0 2 1 5 3 72.7 (8) 4 (2)
Refer for ultrasound 0 0 1 4 6 90.9 (10) 5 (1)

Consensus was accepted in statements that received a level of agreement of more than 75%.
Recommendations that achieved consensus in the management of female infertility included:
1. When treating female patients with infertility, it is important to perform a thorough
history taking
2. When treating female patients with infertility, it is important to repertorise.
3. When treating female patients with infertility, it is important to schedule regular follow-
ups
4. When treating female patients with infertility, it is important to treat layer by layer
5. When treating female patients with infertility, it is important to use nosodes
6. When treating female patients with infertility, it is important to use mother tinctures
7. When treating female patients with infertility, it is important to use gemmotherapy
8. When treating female patients with infertility, it is important to use organotherapy
9. When treating female patients with infertility, it is important to increase fruit & vegetable
intake

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10. When treating female patients with infertility, it is important to eliminate/reduce wheat &
gluten
11. When treating female patients with infertility, it is important to eliminate/reduce sugar &
refined carbohydrates
12. When treating female patients with infertility, it is important to eliminate/reduce dairy
13. When treating female patients with infertility, it is important to recommend eating
frequently throughout the day
14. When treating female patients with infertility, it is important to eliminate/reduce
processed foods
15. When treating female patients with infertility, it is important to eliminate/reduce canola
oil
16. When treating female patients with infertility, it is important to recommend following a
high fibre diet
17. When treating female patients with infertility, it is important to ensure adequate water
intake
18. When treating female patients with infertility, it is important to eliminate alcohol
19. When treating female patients with infertility, it is important to eliminate/reduce caffeine
20. When treating female patients with infertility, it is important to eliminate carbonated
drinks
21. When treating female patients with infertility, it is important to eliminate cigarette
smoking
22. When treating female patients with infertility, it is important to ensure adequate sleep
23. When treating female patients with infertility, it is important to recommend managing
stress
24. When treating female patients with infertility, it is important to prescribe a magnesium
supplement
25. When treating female patients with infertility related to PCOS, it is important to use liver
support
26. When treating female patients with infertility related to PCOS, it is important to use
adrenal support
27. When treating female patients with infertility, it is important to refer to a gynaecologist
28. When treating female patients with infertility, it is important to refer to an endocrinologist
29. When treating female patients with infertility, it is important to refer to an acupuncturist
30. When treating female patients with infertility, it is important to refer to a reflexologist

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31. When treating female patients with infertility, it is important to refer for psychological
care
32. When treating female patients with infertility, it is important to refer for ultrasound

3.7 Summary
This chapter presented the results obtained from the three rounds of questionnaires in this
Delphi study to formulate recommendations on the management of female infertility by
homeopathic practitioners. These recommendations are presented and discussed in the next
chapter.

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CHAPTER FOUR: DISCUSSION OF RESULTS

4.1 Introduction
Chapter four discusses the results of the three phases of the Delphi technique used in this
study. The limitations of the study will also be discussed in this chapter.

4.2 Overview of results

This study aimed to use the Delphi technique to determine the approach of homeopathic
practitioners in South Africa in managing female infertility. The following objectives were
met to achieve this aim:

• Investigate, by means of the Delphi technique, homeopathic practitioners’ experiences

in the management of female infertility;
• Reach expert consensus from homeopathic practitioners on the approach to the
management of female infertility.

4.2.1 The Delphi technique

Fifty homeopathic practitioners, who are considered experts in the management of female
infertility and practicing in South Africa, were invited to participate in this Delphi study.
Potential participants were selected through suggestions given by homeopathic practitioners
and the HSA. These participants were invited with the intention of forming a sample
representative of South African homeopathic practitioners. Of the 50 practitioners invited, 16
practitioners agreed to complete the eligibility survey. Only 12 met all the eligibility criteria
and were invited to commence with the first round of the study, providing recommendations
on the beneficial management of female infertility based on their experience in practice. The
majority of participants were female, and between the ages of 45 to 54 years.

Quantitative data from the first round was presented by percentages, and data from open-
ended questions was classified into categories and sub-categories. The researcher conducted
this analysis, which was confirmed by a qualitative analyst. Responses from the first round
were used to formulate the second round. In the second round, participants were able to rate
the importance of the responses received in the first round and were given the opportunity to
elaborate on previous responses. In the third round, participants rated their level of agreement
with statements from the previous two rounds. A total of 79 statements were taken from

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round one and various additional recommendations were made. These statements were then
placed into four categories: therapeutic interventions, dietary and lifestyle modifications,
supplementation, and referrals. All statements were used in the third round, and 32 achieved
participant consensus. Consensus was reached when the participant agreement on a statement
was 75% or more. Twelve participants completed rounds one and two however, one
participant did not complete the third round, stating that they were unable to due to time
constraints, therefore only eleven participants completed the third round of the study.

4.3 The approach of homeopathic practitioners in South Africa to female infertility

Infertility is a relatively common condition that affects approximately 8-12% of couples
worldwide (Vander Borght and Wyns, 2018). Infertility has been shown to be associated with
various psychological disorders, namely anxiety, depression, social isolation, and sexual
dysfunction (Courbiere et al., 2020). Homeopathy is a therapeutic practice that uses the
concept of ‘like cures like’ to prescribe highly diluted, potentised remedies to treat illness
(Donelli and Antonelli, 2021). Homeopaths in South Africa are also allowed, as per their
scope of practice, to offer dietary advice and health supplementation to their patients.
Information was gathered regarding the management approach of South African homeopathic
practitioners to female infertility. Participants reported useful aspects of case management,
homeopathic treatments, dietary recommendations, lifestyle adjustments, supplements, and
referrals.

4.3.1 Case management

Participants recommended multiple aspects of case management that are potentially useful in
the management of female infertility. The recommendations that achieved consensus include
thorough history taking, repertorisation, scheduling regular follow-up consultations and
treating layer by layer.

History taking is a process used by healthcare providers to gather information about a patient
that guides treatment (Nichol et al., 2021). Two aspects of history taking were discussed in
this study: homeopathic and biomedical history taking. Homeopathic history taking gathers
information on the main complaint, additional symptoms, personal and family medical
history, and findings of the physical examination. Homeopathic history taking is more in-
depth than conventional case taking and promotes open expression from the patient without
feeling interrogated. This process is done with the main goal of selecting the correct remedy,

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the simillimum (Prousky, 2018). Biomedical history taking focuses on the individual and
family medical history, medication use, surgical history, and allergies. Studies have shown
that a thorough history taking, utilising open-ended questions and listening to responses, is an
essential tool in reaching a diagnosis, guiding care and avoiding harmful reactions to the
prescribed treatment. Many healthcare providers often rush case taking or interrupt patients to
save time, however it has been found that taking a comprehensive history ultimately saves
time in reaching a diagnosis. In addition, interrupting patients dramatically increases the
likelihood of missing information that is potentially crucial to the case (Muhrer, 2014; Nichol
et al., 2021).

Repertorisation is a process in which symptoms and modalities are classified into rubrics,
using a homeopathic repertory, and then graded to select the most appropriate homeopathic
remedy for a specific case. A homeopathic repertory is an index of symptoms and modalities,
listed as rubrics and sub-rubrics, which are graded. Repertorisation has been identified as a
useful tool to homeopathic practitioners in selecting the correct remedy, particularly in
complicated cases (Kumar, 2019).

A follow-up consultation is a consultation set on a date following the initial consultation to

monitor the patient’s progress since commencing treatment. Follow-up consultations give
patients the opportunity to ask questions, address concerns and have their treatment adjusted
where necessary. In addition, physicians are given the opportunity to discuss any special
investigations requested previously, identify changes in symptoms or new symptoms and
adjust treatment appropriately. They are also a useful tool in improving patient-physician
relationships (Agency for Healthcare Research and Quality, 2020). Studies have shown that
follow-up consultations often consist of these elements: questions by the physician regarding
disease progression, recommendations by the physician and questions from the patient.
Studies show that patients respond better to the physician if focus is placed on the patient’s
desired treatment outcome (Brand and Stiggelbout, 2013). A study done by Price et al. (2020)
found that patients who attend frequent follow-up consultations are more likely to feel that
they have access to routine care.

The practice of addressing a case layer by layer was described by homeopath, Dr Francisco
Eizayaga. Eizayaga believed that different remedies should be prescribed for each layer of a
case. There are different layers: the miasmatic, constitutional, fundamental and lesion layers.

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The miasmatic layer refers to hereditary predispositions that affect an individual. The
constitutional layer focuses on the unique characteristics of an individual; treatment of this
layer is not focused on pathology but on the healthy state of the person. The fundamental
layer involves the acquired traits that a person develops through various experiences in their
lives. The lesion layer relates to disease and treatment of this layer is entirely clinical (Owen
Homoeopathics, n.d.). There is scarce research available on the concept of treating layer by
layer.

4.3.2 Homeopathic treatment

Multiple treatments used by homeopathic practitioners were noted by participants and rated
for their importance in the management of female infertility. The homeopathic treatments that
achieved consensus include nosodes, mother tinctures, gemmotherapy and organotherapy.

[Link] Nosodes
Nosodes are homeopathic remedies obtained from the preparation and potentisation of
diseased tissue or a pathogen causing a certain disease. These remedies are prescribed to treat
or prevent the same disease from which the remedy was prepared (Rieder and Robinson,
2015). Research on the use of nosodes for female infertility is scarce. A report by Haresnape
Tyson (2015) found that nosodes are sometimes used in infertility related to infection, either
current or previous. The specific recommendations for nosodes that participants considered
useful in managing female infertility included Folliculinum in 12X, 30cH and 200cH
potencies, Carcinosin in 200cH and 10M potencies, Medorrhinum in 200cH and 10M
potencies, Syphilinum, Thyroideum in 9cH and 30cH potencies, and Variolinum in 200cH
potency.

• Folliculinum
Folliculinum is a homeopathic remedy made of estrone that is commonly used in the
management of hyperandrogenism, PCOS, uterine fibroids, breast cysts, dysmenorrhoea,
endometriosis, and secondary amenorrhoea after pregnancy (Damasceno et al., 2020).
Folliculinum is similar in its indications to Carcinosin and is sometimes referred to as the
‘hormonal Carcinosin’. Indications for Folliculinum often include the tendency to neglect
themselves for the sake of others, a history of prolonged use of oral contraceptives, loss of
will power, the desire to meet expectations of others and the sense that they are controlled by
others (Leupen, 2014). Folliculinum has been mentioned as a useful treatment in cases where

69
ovarian function is decreased after numerous courses of fertility treatment (Gaware et al.,
2009).

• Carcinosin
Carcinosin is a homeopathic nosode made of cancerous tissue, often breast cancer cells, that
is prepared homeopathically and is used in the management of various cancers including
breast cancer and osteosarcoma (Bell et al., 2014). A case study by Sabharwal and
Deorukhkar (2020) prescribed Carcinosin for a 30-year-old female with oligomenorrhoea
diagnosed with PCOS. In this case, her menstrual cycles became regular, follicular
development improved and she was able to conceive within 6 months of the initial
prescription. The homeopathic indications for Carcinosin, which were met in this case,
include a history of cancer, responsibility from a young age, anxiety about health and family
and ailments from domination by others.

• Medorrhinum
Medorrhinum is a remedy prepared from gonorrhoeal secretions, that is often indicated in
chronic disorders caused by suppressed gonorrhoea and pelvic disorders in women (Das and
Kumar Thangellapelli, 2017; Rajasimhan et al., 2021). According to the Repertory of
Homoeopathic Nosodes and Sarcodes by Berkeley Squire, Medorrhinum is indicated in cases
of female infertility (Squire, 2003) and Gaware et al. (2009) suggests that Medorrhinum is
particularly useful in infertility related to endometriosis.

• Syphilinum
Syphilinum is a homeopathic remedy prepared from the virus associated with Syphilis
(Treponema pallidum) (Shah, 2014). Syphilinum is sometimes referred to as the ‘nosode of
destruction’ and has the following main indications: antisocial, tendency to lie, abusive,
indifference to the future and desperation (Earnest, 2011). There is scarce research available
on the benefits of prescribing Syphilinum in cases of female infertility.

• Variolinum
Variolinum is a homeopathic remedy prepared from the fluid from a smallpox pustule. It is
generally used to prevent and treat a smallpox infection (Boericke, 1927). To date, there is no
research available on the usefulness of Variolinum in the management of female infertility.

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[Link] Mother tinctures
Mother tinctures are liquid preparations of raw plant material mixed with alcohol or water,
usually in a 1:10 dilution. The methods involved in the preparation of homeopathic mother
tinctures are laid out a homeopathic pharmacopoeia (Banerjee, 2006; O’Connor, 1890;
Scheepmaker and Gower, 2011). The evidence and indications below are based on
information available on herbal tinctures and extracts as research on homeopathic mother
tinctures is limited. Participants recommended specific mother tinctures that are useful in
female infertility in round two of this study. These recommendations related to specific
underlying conditions related to female infertility, namely female hormonal disorders,
impaired adrenal function, and thyroid disorders. Although consensus was not determined for
any specific mother tincture, those indicated by participants to be useful will be discussed in
more detail here.

• Mother tinctures for female hormonal disorders

Female hormonal disorders that are commonly related to infertility include PCOS,
endometriosis, hypogonadotropic hypogonadism, hyperprolactinaemia, and primary ovarian
insufficiency (Brichant et al., 2021; McGowan, 2011; Unuane et al., 2011). Thyroid and
adrenal disorders are also hormonal disorders associated with female infertility but are
discussed separately. The mother tinctures noted to be useful in infertility related to female
hormonal disorders included Vitex agnus-castus, Glycyrrhiza glabra, Angelica sinensis,
Actaea racemose, Thuja occidentalis, Carduus marianus, Asparagus racemosus, Paeonia
lactiflora, Eleutherococcus senticosus, Rhodiola rosea, Panax ginseng, Humulus lupulus,
Calendula officinalis, and Angelica archangelica.

Vitex agnus-castus
Vitex agnus-castus, also called chaste tree, is commonly used as a treatment for hormonal
imbalances in females. It acts on the pituitary gland to increase levels of progesterone,
through increasing levels of LH (Montgomery Hays and Hudson, 2020). It has been proven to
be beneficial in cases of decreased progesterone and hyperprolactinaemia, which is associated
with various menstrual abnormalities (Hechtman, 2020). A recent study has shown that Vitex
agnus-castus is useful in the treatment of PCOS through the downregulation of kisspeptin, a
neuropeptide that controls various aspects of fertility through feedback systems of sex
hormones (Feyzollahi et al., 2021). Overall, the compounds in this plant have been shown to
regulate hormonal imbalances and improve symptoms of PCOS, premature ovarian failure,

71
hypothalamic dysfunction, hyperprolactinaemia, and endometriosis, with the additional
benefit of having anti-cancer, anti-depressant and antioxidant properties (Akbaribazm et al.,
2021). It has also been shown to inhibit prolactin secretion – elevated prolactin inhibits the
development of the corpus luteum, thereby decreasing progesterone secretion which is
associated with infertility (Van Die et al., 2013).

Glycyrrhiza glabra
Glycyrrhiza glabra, commonly known as liquorice, belongs to the Fabaceae family and has
been shown to have anti-bacterial, anti-viral, anti-inflammatory, anti-diabetic, and antioxidant
properties (Pastorino et al., 2018). Multiple laboratory studies have been done to investigate
the effects of Glycyrrhiza glabra on PCOS; results indicated that Glycyrrhiza glabra
significantly decreases levels of free and bound testosterone, increases levels of oestradiol
and increases ovulation rates in women with PCOS (Arentz et al., 2014).

Angelica sinensis
Angelica sinensis, or Dong-quai, has been shown to be cardioprotective, anti-arrhythmic,
anti-atherosclerotic and immune system enhancing. Angelica sinensis is commonly known
as female ginseng because it is well-known for its benefits in gynaecological disorders
such as menopausal complaints, PMS, dysmenorrhoea, and amenorrhoea. Studies have
also shown that it inhibits the activity of oestrogen (Chen et al., 2020a; Jiao et al., 2022;
Wei et al., 2016;).

Actaea racemosa
Actaea racemosa, or black cohosh, is part of the Ranunculaceae family and has been used
successfully in the treatment of muscular pain, headaches, inflammation, dysmenorrhoea, and
climacteric complaints (Salari et al., 2021; Wuttke et al., 2014). A laboratory study found
that Actaea racemose taken with clomiphene increases levels of luteinising hormone (LH)
and three RCTs found that it improves pregnancy rates in women with PCOS as compared to
taking clomiphene alone (Arentz et al., 2014).

Thuja occidentalis
Thuja occidentalis, or white cedar, is widely used as an antioxidant, anti-inflammatory,
antibacterial, antifungal, antiviral, hepatoprotective, antipyretic and anti-cancer agent. It has
also been shown to be regulate lipid metabolism and protect against radiation by increasing

72
the activity of the anti-tumour factors tumour necrosis factor alpha (TNF-α), interleukin-6
(IL-6) and interleukin-1 (IL-1) (Caruntu et al., 2020; Dinarello, 2018; Jang et al., 2021;
Uciechowski and Dempka, 2020). Thuja occidentalis has also been found to increase
oestradiol and progesterone levels, decrease LH and testosterone levels, and reduce levels of
low-density lipoprotein (LDL) cholesterol and glucose in cases of PCOS (Küpeli Akkol et
al., 2015).

Carduus marianus
Carduus marianus, also known as milk thistle, has antifibrotic, anti-inflammatory,
antioxidant, and regenerating actions on the liver (Abenavoli et al., 2018). Relative to female
hormonal disorders, milk thistle has been shown to have weak oestrogenic activities and
inhibit aromatase activity, however there is no evidence that Carduus marianus affects
oestrogen metabolism (Dietz et al., 2016).

Asparagus racemosus
Asparagus racemosus, commonly known as shatavari, has been found to have anti-bacterial,
antioxidant, immunomodulatory, antitussive and hepatoprotective properties (Anders et al.,
2020). Research has shown that shatavari improves female fertility by improving hormonal
imbalances, oocyte quality, follicular growth and PCOS. It is also useful in managing the
psychological stress related to female infertility (Pandey et al., 2018).

Paeonia lactiflora
Paeonia lactiflora, also called Chinese Peony, is a herb used in TCM to treat a range of
painful and inflammatory disorders such as rheumatoid arthritis, migraine headaches,
ulcerative colitis and Parkinson’s disease (Du et al., 2020; Liao et al., 2019; Zhang and Dai,
2012; Zhang et al., 2019). Studies have found that Paeonia lactiflora is potentially beneficial
in the treatment of PCOS; its root improves excessive secretion of testosterone associated
with PCOS by downregulating CYP17A1 and cytochrome P450 side chain cleavage
(P450scc) (Lai et al., 2017; Ong et al., 2019; Slominski et al., 2015).

Eleutherococcus senticosus
Eleutherococcus senticosus (Siberian ginseng) is used to stimulate the immune system,
improve fatigue, enhance memory, and prevent cancer (Cichello et al., 2015; Yamauchi et
al., 2019). Eleutherococcus senticosus is useful in female infertility for its effects as an

73
adaptogen and is often used as a general tonic. However, Siberian ginseng has been shown to
inhibit COMT which is essential for the processing of oestrogen metabolites (Cordts et al.,
2014; Figueiredo and Fernandes, 2021; Liao et al., 2018). Research regarding the
effectiveness of Eleutherococcus senticosus in managing female infertility is scarce.

Rhodiola rosea
Rhodiola rosea has anti-aging, immunomodulatory, anti-inflammatory, and anti-cancer
effects. It also enhances physical and mental performance in cases of exhaustion, weakness
and decreased concentration, and is considered an adaptogen (Li et al., 2017; Panossian et al.,
2021). Rhodiola rosea assists the body in managing the effects of stress through its effect on
the hypothalamic-pituitary-adrenal (HPA) axis (Tireki, 2021). A report by Gerbarg and
Brown (2016) found that Rhodiola rosea has selectively modulating effects on oestrogen
receptors.

Panax ginseng
Panax ginseng (Korean ginseng) is an antioxidant, anti-cancer, anti-diabetic and regulatory
agent in vasomotor function and allergies (Kim, 2018). A study done on rats found that
Panax ginseng promotes folliculogenesis through its effect on the HPA axis, induction of the
proliferation of ovarian cells and downregulation of apoptotic markers (Faghani et al., 2022).
Panax ginseng has been shown to have a potent oestrogenic effect; it upregulates ERα and
ERβ. ERβ in turn counteracts stress through antioxidant and anti-apoptotic effects. For these
reasons, this herb is often used as a supportive treatment for menopausal symptoms (Park et
al., 2017).

Humulus lupulus
Humulus lupulus (hops) is generally indicated in cases of anxiety, mood disorders, and
restlessness due to its sedative properties (Franco et al., 2012; Kyrou et al., 2017). Evidence
also shows that hops contain phytoestrogens and can therefore be considered as an alternative
to hormone replacement therapy during menopause. However, phytoestrogens may
potentially cause impaired oocyte maturation and caution should be taken in cases of
infertility (Tronina et al., 2020).

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Calendula officinalis
Calendula officinalis is typically used as an anti-inflammatory and antibacterial agent that
assists in wound healing (Parente et al., 2012). There is no research available for the
effectiveness of Calendula officinalis in female hormonal imbalances or infertility.

Angelica archangelica
Angelica archangelica is a herb that is often used to manage disorders such as anxiety,
insomnia, anorexia, migraines, dermatological diseases, arthritis and respiratory complaints
(Kumar et al., 2013; Sowndhararajan et al., 2017). There is scarce research available on the
usefulness of Angelica archangelica in female hormonal disorders.

• Mother tinctures for impaired adrenal function

Adrenal insufficiency is a condition in which the adrenal gland’s secretion of its hormones,
mainly cortisol and aldosterone in these cases, is impaired. The severity of this condition
ranges from mild, vague symptoms to a state of life-threatening shock (Huecker et al., 2022).
The mother tinctures that were recommended for the management of female infertility related
to impaired adrenal function included Withania somnifera, Glycyrrhiza glabra, Scutellaria
lateriflora, Panax ginseng, Valeriana officinalis, Passiflora incarnata, Eleutherococcus
senticosus, Rhodiola rosea, Schisandra chinensis, Ginkgo biloba, Cordyceps, and Vitex
agnus-castus.

Withania somnifera
Withania somnifera, also called Indian Ginseng or Ashwagandha, has been identified as an
effective treatment for insomnia, chronic stress, schizophrenia, obsessive-compulsive
disorder, rheumatoid arthritis, and diabetes mellitus type 2. It has also shown positive results
in enhancing cognition and improving parameters of fertility in both males and females. In
addition to improving female fertility, a RCT done in 2015 found that Ashwagandha
significantly improved scores of the Female Sexual Function Index (FSFI) and the Female
Sexual Distress Scale (FSDS) (Tandon and Yadav, 2020). Another study supported these
findings and added that it is useful in managing hypoactive sexual desire disorder (HSDD),
female sexual arousal disorder (FSAD) and female orgasmic disorder (FOD) (Dongre et al.,
2015).

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Glycyrrhiza glabra
Glycyrrhiza glabra (liquorice) has previously been discussed for its usefulness in the
management of PCOS. Glycyrrhiza glabra possesses mineralocorticoid properties, although
significantly weaker than aldosterone itself, and has been noted as a potential treatment in
adrenal insufficiency. Liquorice is widely used for the management of chronic fatigue
syndrome and Addison’s disease, due to its ability to reduce the inactivation of cortisol even
in cases of reduced cortisol production. It also increases the half-life of cortisol and supports
the anti-inflammatory activity of cortisol (Murray, 2020; Sabbadin et al., 2019).

Scutellaria lateriflora
Scutellaria lateriflora (American skullcap) is a medicinal herb that is often used for the
management of neuropsychiatric conditions such as anxiety, insomnia, depression,
fibromyalgia, Parkinson’s disease, panic attacks and Alzheimer’s disease (Lohani et al.,
2013; Sandasi et al., 2014; Uritu et al., 2018). It has been identified as a useful anxiolytic that
significantly improves mood, energy and cognition particularly in cases of coexisting
depression (Brock et al., 2013). There is little research available on the use of Scutellaria
lateriflora for female infertility.

Panax ginseng
Panax ginseng has been discussed previously for its usefulness in managing female infertility
related to female hormonal disorders. Panax ginseng has been shown to successfully regulate
hormonal responses to stress by adjusting the HPA axis, maintaining homeostasis and
improving the body’s response to stressful stimuli (Lee and Rhee, 2017). Panax ginseng was
also found to be useful in managing pathological fatigue, fatigue that does not improve with
rest, and the physical and mental conditions associated with it (Lu et al., 2021).

Valeriana officinalis
Valeriana officinalis is a widely used medicinal plant for anxiety, insomnia, and
gastrointestinal spasms; it is recognised as one of the most effective herbal sedatives.
Valepotriates, compounds found in Valeriana officinalis, have anxiolytic and anti-depressant
effects by modifying the HPA axis and restoring endocrine balance (Orhan, 2021; Shinjyo et
al., 2020).

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Passiflora incarnata
Passiflora incarnata, commonly known as passionflower, has been found to be useful in
reducing stress, anxiety, insomnia, and depression. It has also been found to improve the
effects associated with chronic stress and to improve memory impairments (Janda et al.,
2020).

Eleutherococcus senticosus
Eleutherococcus senticosus has previously been discussed for its usefulness in treating
female infertility related to hormonal imbalances. Eleutherococcus senticosus is considered
an adaptogen, meaning it assists in the body’s appropriate and effective response to external
influences. It has been shown to catalyse the degradation of stress hormones, making them
inactive (Liao et al., 2018). A study done on 357 participants found that Eleutherococcus
senticosus improves mental performance and decreases the activity of the adrenal cortex and
sympathetic nervous system under stressful conditions (Panossian and Wikman, 2010).

Rhodiola rosea
Rhodiola rosea was previously discussed as a recommendation for female infertility related
to hormonal imbalances. In addition to regulating the HPA axis, the administration of
Rhodiola rosea has shown to reduce corticotropin-releasing hormone and corticosterone
under stressful conditions (Tireki, 2021; Xia et al., 2016).

Schisandra chinensis
Schisandra chinensis is widely used in TCM as an adaptogen, anti-diabetic and
hypoglycaemic agent, central nervous system stimulant, hepatoprotective agent, anti-
carcinogen, and antimicrobial. It has also shown promising results for its preventative effects
against aging skin, osteoarthritis, mitochondrial dysfunction, and cognitive disorders (Nowak
et al., 2019; Rybnikář et al., 2019). A study done on rats found that Schisandra chinensis
decreases blood cortisol and glucose levels under stressful conditions. It also exhibits a
protective effect over the adrenal cortex and decreases the incidence of negatively affected
immunity related to psychological and physical stress (Li et al., 2015).

Ginkgo biloba
Ginkgo biloba is a commonly used herbal supplement indicated for cognitive impairment,
CVD, depression, sexual dysfunction, vertigo, tinnitus, vitiligo, macular degeneration,

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glaucoma, and altitude sickness (Nguyen and Alzahrani, 2022). The use of Ginkgo biloba has
also been shown to reduce cortisol secretion under acute stress (Camfield et al., 2013).
Ginkgolide B and allopregnanolone, constituents of Ginkgo biloba, have been shown to
suppress folliculogenesis and oogenesis, and to promote apoptosis of ovarian cells. This
suggests that it may suppress reproductive processes (Sirotkin, 2021).

Cordyceps
Cordyceps is a fungus that has been shown to be useful in diabetes mellitus, hyperlipidaemia,
fungal infections, inflammation, cancer, viral infections, HSDD, CVD, malaria, osteoporosis,
arthritis, and aging (Ashraf et al., 2020). A type of Cordyceps, Cordyceps militaris has been
found to be effective in preventing fatigue in stressful situations (Song et al., 2015). There is
abundant evidence that Cordyceps is useful in treating male infertility, but scarce research on
the use of Cordyceps for female infertility (Ashraf et al., 2020).

Vitex agnus-castus
Vitex agnus-castus, commonly known as chaste tree or chasteberry, is a commonly used
medicinal plant for gynaecological complaints such as premenstrual syndrome, premenstrual
dysphoric disorder, hyperprolactinaemia, and cyclic mastalgia (Cerqueira et al., 2017; Ooi et
al., 2020; Van Die et al., 2013). In contrast to participants’ recommendations, a laboratory
study done on rats found that Vitex agnus-castus has anxiogenic effects (Yaghmaei et al.,
2012). There is little evidence that Vitex agnus-castus is beneficial in the treatment of adrenal
impairment but there is abundant evidence on its usefulness in female infertility related to
hormonal disorders, as previously discussed.

• Mother tinctures for thyroid disorders

Thyroid dysfunction has been linked to various menstrual disorders, low ovarian reserve, and
infertility (Dosiou, 2020). The mother tinctures that were noted by participants to be
beneficial in the management of female infertility related to thyroid disorders included
Withania somnifera, Fucus vesiculosus, Bacopa monnieri, and Glycyrrhiza glabra.

Withania somnifera
Withania somnifera (Indian Ginseng or Ashwagandha) has been discussed previously for its
usefulness in managing female infertility related to adrenal impairment. Ashwagandha is
often used to treat thyroid disorders and has been found to be effective in normalising levels

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of the thyroid hormones, namely thyroid stimulating hormone (TSH), triiodothyronine (T3 )
and thyroxine (T4 ) (Sharma et al., 2018).

Fucus vesiculosus
Fucus vesiculosis (bladderwrack) is often used as an aid in weight loss, hypertriglyceridemia,
non-alcoholic steatohepatitis, and osteoarthritis (Gabbia et al., 2017; Myers et al., 2016;
Ponnam et al., 2021; Ventura et al., 2018). The iodine content of Fucus vesiculosis makes it a
useful option in hypothyroidism and obesity, but caution should be taken in cases of
hyperthyroidism (Arbaizar and Llorca, 2011; Catarino et al., 2018). There is scarce research
available on the use of Fucus vesiculosis in female infertility.

Bacopa monnieri
Bacopa monnieri (Brahmi) is a medicinal herb that is used to improve memory and cognitive
function; it is also useful in the prevention and treatment of Alzheimer’s disease,
schizophrenia, Parkinson’s disease, and stroke. A study done on mice found that the
administration of Bacopa monnieri increases T4 levels and could thus be considered
potentially useful in the treatment of hypothyroidism (Mathur et al., 2016; Sukumaran et al.,
2019).

Glycyrrhiza glabra
Glycyrrhiza glabra has been discussed previously for its use in female infertility related to
hormonal disorders and adrenal impairment. There is scarce evidence that Glycyrrhiza glabra
may be useful in improving thyroid function.

[Link] Gemmotherapy
Gemmotherapy is a branch of phytotherapy that uses the therapeutic benefit of meristematic
plant tissue. Plant buds are macerated in water, alcohol, and glycerol to produce the glycerine
macerates of gemmotherapeutic remedies in a D1 potency (Di Vito et al., 2020). Specific
gemmotherapy remedies were recommended by participants in round two in relation to
certain conditions. These conditions included: female hormonal disorders, impaired adrenal
function, and thyroid disorders. Although consensus was not determined for any specific
gemmotherapy remedy, those indicated by participants to be useful will be discussed in more
detail here.

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 • Gemmotherapies for female hormonal disorders
The gemmotherapies noted to be useful in managing female infertility related to hormonal
disorders include Rubus ideaus, Vaccinium vitis-idaea, Tilia tomentosa, Ribes nigrum,
Viburnum opulus, and Juniperus communis.

Rubus ideaus
Rubus idaeus (raspberry) is often prescribed for its antimicrobial and antioxidant effects in
the common cold, fever, and influenza (Krauze-Baranowska et al., 2014). It has also been
described as a useful gemmotherapeutic in the reproductive and menopausal stages of a
woman’s life and is often given during pregnancy to prevent miscarriage, morning sickness
and premature birth. Although it is popular in pregnancy, its actual purpose is to improve
blood flow to the uterus and ease uterine muscle contractions (Grigoriu et al., 2021; Rakel,
2018). Research on the usefulness of raspberry as a gemmotherapy to manage female
infertility or female hormonal disorders is scarce.

Vaccinium vitis-idaea
Vaccinium vitis-idaea (lingonberry) has been used for its properties as an antioxidant, anti-
carcinogenic and anti-inflammatory agent. It has also been shown to prevent and treat
neurodegenerative disorders (Kowalska, 2021; Ryyti et al., 2020). Research on the use of
Vaccinium vitis-idaea in the management of female infertility related to hormonal disorders is
scarce.

Tilia tomentosa
The buds of Tilia tomentosa have been shown to be useful sedatives and anxiolytics by
strengthening inhibitory outputs of synapses (Allio et al., 2015). To date, there is no research
available that supports the effectiveness of Tilia tomentosa on female hormonal imbalances
or female infertility.

Ribes nigrum
Ribes nigrum (blackcurrant) buds are known for their use as a general tonic to improve
overall health and for their antiseptic, antioxidant, anti-carcinogenic and diuretic effects.
Ribes nigrum has also been shown to be a phytoestrogen (Donno et al., 2013; Nanashima et
al., 2015; Oprea et al., 2008). Research on the effects of Ribes nigrum as a gemmotherapy in
female hormonal imbalances is scarce, however there is evidence that herbal preparations

80
lower glucose and insulin levels in the blood after a meal, which may be useful in patients
with PCOS (Lappi et al., 2021).

Viburnum opulus
Viburnum opulus (cramp bark) is often used for the management of cough, tuberculosis,
gastrointestinal complaints, renal complaints, diabetes mellitus, obesity, and joint pains. It is
also a useful antioxidant, anti-inflammatory, and antimicrobial. The herbal preparation of
Viburnum opulus has been shown in animal studies to have relaxant effects on uterine
muscle, making it useful in the management of dysmenorrhoea (Kajszczak et al., 2020;
Zengion and Yarnell, 2011). In folk medicine, it has been used for ovarian cysts. Research
has also shown that extracts of Viburnum opulus from herbal preparations significantly
decreases adhesion and volume of endometriotic lesions and peritoneal cytokine levels (Ilhan
et al., 2019; Balan et al., 2021). There is scarce research available on the use of Viburnum
opulus as a gemmotherapy.

Juniperus communis
Juniperus communis is a plant that is commonly used for the management of arthritis,
diabetes mellitus, autoimmune disease, hyperlipidaemia, and gastrointestinal disorders, as
well as for its diuretic, antiviral, antibacterial, antioxidant, antifungal, and anti-inflammatory
properties. Juniperus communis has been found to have anti-progestational activity and has
been found to prevent implantation in doses of 300mg-500mg per kilogram of body weight.
Some studies advise that this should not be given to women planning on conceiving, as it has
been shown to have abortifacient effects in animal studies, however these studies have been
conducted on herbal preparations of Juniperus communis (Daniyal and Akram, 2015; Raina
et al., 2019). There is scarce research available on the usefulness of Juniperus communis as a
gemmotherapy in the management of female infertility.

[Link] Organotherapy
Organotherapy, often called sarcode therapy, is a type of homeopathic prescribing in which
remedies are prepared from healthy secretions, tissues, or organs and potentised according to
homeopathic principles to promote optimal organ function. Organotherapy is based on two
principles: the administration of a healthy organ may rectify the function of a diseased organ
and the activity of the remedy is dependent on the potency in which it is prescribed
(Bioregulatory Medicine Institute, n.d.). Organotherapies that were specifically mentioned

81
but did not obtain consensus for their use in female infertility include Adrenal gland, Ovary,
Thyroidinum in 9cH and 30cH, Liver, Progesterone, Oestrogen in 4cH, 7cH and 9cH,
Testosterone, Uterus, Fallopian tube, Pituitary gland, Endometrium, and proprietary
homeopathic complexes Ovarium compositum, Hormeel and R20. There is scarce research
available on the usefulness of these remedies, however the main goal of their administration
is to improve the function of the organ from which they are made (Bioregulatory Medicine
Institute, n.d.). Although consensus was not determined for any specific organotherapy
remedy, those indicated by more than one participant to be useful in female infertility will be
discussed further.

Thyroidinum
The thyroid gland is in the anterior part of the neck and assists in regulating various bodily
functions through the secretion of T3 and T4 (Armstrong et al., 2022). Thyroidinum is a
homeopathic remedy prepared from dried thyroid gland, usually from a sheep (Boericke,
1927). Thyroidinum has been recommended as a beneficial remedy in cases of infertility
related impaired thyroid function (Baranwal et al., 2016).

Ovarium compositum
Ovarium compositum is available as an injectable and is a complex of organ remedies and
other homeopathic remedies: Ovary D8, Placenta D10, Uterus D10, Fallopian tube D10,
Hypophysis D13, Cypripedium calceolus D6, Lilium tigrinum D4, Pulsatilla pratensis D18,
Aquilegia vulgaris D4, Sepia officinalis D10, Lachesis muta D10, Apisinum D8, Kreosotum
D8, Bovista D6, Ipecacuanha D6, Mercurius solubilis D10, Hydrastis canadensis D4,
Aconiticum acidum D10, and Magnesium phosphoricum D10. This complex is indicated in
dysmenorrhoea, menorrhagia, mastodynia, craurosis vulvae, endometritis, decreased activity
of the anterior pituitary gland in females and infertility related to ovarian dysfunction (United
Remedies, n.d.c)

R20
R20 drops are a combination of various organotherapies: Thymus D12, Thyroid D12,
Hypophysis D12, Pancreas D12, Adrenal gland D12, and Ovary D12. It is indicated in cases
of endocrine disturbances such as growth disorders, obesity because of pituitary disorders,
Grave’s disease and Addison’s disease (United Remedies, n.d.a).

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4.3.3 Dietary and lifestyle modifications
Various recommendations were made regarding dietary and lifestyle modifications that
should be undertaken by someone undergoing treatment for female infertility.

[Link] Dietary modifications

Research has shown that diet plays an important role in female fertility (Panth et al., 2018).
The dietary modifications that achieved consensus in this study included: increasing fruit and
vegetable intake, eating frequently throughout the day, following a high fibre diet, adequate
water intake, and eliminating/reducing wheat & gluten, sugar and refined carbohydrates,
dairy, processed foods, canola oil, alcohol, caffeine, and carbonated drinks.

• Increasing fruit and vegetable intake

Aside from providing basic dietary nutrients, fruits and vegetables have been found to reduce
inflammation and potentially prevent various chronic diseases due to their antioxidant
activity. They are essential to a healthy diet as they contain a high nutrient density, high fibre
content and low energy density (Wallace et al., 2020). The World Health Organisation
recommends that an adult should consume at least 400g, or five portions, of fruit and
vegetables per day. This recommendation excludes starchy vegetables such as potato,
cassava, and sweet potato (World Health Organisation, 2020). Diets that favour fruit and
vegetable intake are associated with improved fertility in women (Gaskins and Chavarro,
2018).

• Eliminating/reducing wheat & gluten

Gluten is a protein found in wheat, rye, barley, and oats which are commonly consumed
globally. Diets high in gluten are associated with obesity, diabetes mellitus type 2 and various
allergic reactions (Biesiekierski, 2017; Sabença et al., 2021; Shewry and Hey, 2016).
Females with unexplained fertility have been found to have three times higher risk of
developing coeliac disease. A gluten free diet in females with coeliac disease has been
observed to improve fertility and improve the outcomes of ART (Krawczyk et al., 2022).

• Eliminating/reducing sugar & refined carbohydrates

Diets which eliminate carbohydrates to replace them with protein or fat have become popular
in recent years. Studies have shown that a moderate carbohydrate intake (50-55% of total
energy intake) is the most favourable option, with low intake (less than 40%) and high intake

83
(greater than 70%) being associated with higher mortality rates. However, it has also been
found that mortality rates decrease when carbohydrates are substituted by plant-based fats
and proteins, as opposed to animal fats and proteins (Seidelmann et al., 2018). There is
significant evidence showing that decreasing carbohydrate intake improves female fertility by
decreasing insulin levels, promoting ovulation, and improving hormonal balance (McGrice
and Porter, 2017).

• Eliminating/reducing dairy
Dairy products are valuables sources of vitamins, minerals, protein, and probiotics. An
analysis of 2 154 studies concluded that the consumption of dairy does not increase the risk
of all-cause mortality. The risks of overconsumption of dairy products is predominantly
related to the salt, sugar and saturated fats added to these products (Cavero-Redondo et al.,
2019; Comerford et al., 2021;). Dairy is often considered detrimental to reproductive function
in women because of its high content of oestrogens and laboratory studies have shown that
galactose may cause premature ovarian failure and decreased ovulation (Gaskins and
Chavarro, 2018). Afeiche et al. (2016) found no association between dairy intake and
infertility whilst Chavarro et al. (2007) found that dairy products high in fat are beneficial to
fertility, but low-fat dairy products may increase the risk of anovulatory disorders. There is
inconsistent evidence that dairy intake may affect fertility in females.

• Eating frequently throughout the day

The recommendation by participants was to avoid long periods of fasting between meals.
This is in contradiction to recent research which highlights the benefits of extending times
between meals. It is recommended that breakfast and lunch are five to six hours apart, and
dinner and breakfast the next morning should be 18 to 19 hours apart. Additional evidence
states the benefits of consuming majority of the daily calories earlier in the day and a small
proportion in the evenings. This practice has been associated with decreased risk of obesity
(Kahleova et al., 2019; Paoli et al., 2019). Intermittent fasting, the practice of fasting
periodically, has been shown to decrease androgen levels and increase sex hormone binding
globulin (SHBG) in obese women which may be useful in the management of PCOS
(Cienfuegos et al., 2022; Stockman et al., 2018).

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 • Eliminating/reducing processed foods
Processed foods are foods prepared with processed culinary ingredients (fats, oils, sugar and
salt) and minimally processed foods. Minimally processed foods are animal or plant products
that have not undergone processing, apart from minimal processing designed to preserve
foods for storage, make them more palatable or make them safer for consumption (Elizabeth
et al., 2020). Ultra-processed foods contain little to no intact food and are formulated from
food derivatives with colouring, flavouring, emulsifiers, and sweeteners. Examples of ultra-
processed foods are sweets, chocolates, cooldrinks and reconstituted meats (Chen et al.,
2020; Elizabeth et al., 2020). Studies have found a positive correlation between the
consumption of ultra-processed foods and the development of cancer, CVD, diabetes mellitus
type 2, irritable bowel syndrome (IBS), depression and asthma (Elizabeth et al., 2020). Nazni
(2014) recommends eliminating processed foods to optimise fertility.

• Eliminating/reducing canola oil

Canola oil is the oil extract of a flowering plant of the Brassicaceae family, canola. Studies
show that canola oil significantly reduces circulating LDL and total cholesterol, improves
insulin resistance, and increases levels of tocopherol/vitamin E in the blood. In addition,
research shows that cooking with canola oil instead of butter or margarine is related to
reduced cardiometabolic mortality (Lin et al., 2013; Zhang et al., 2021). Intake of trans-fatty
acids and saturated fats found in canola oil has been shown to be detrimental to female
fertility. However, canola oil also contains monounsaturated fatty acids which have been
found to improve fertility (Skoracka et al., 2021). It should be noted that the process of
extraction used for canola affects its beneficial or harmful effects. There are various methods
used in the processing and extraction of canola oil which have been found to promote the
addition of trans fats and the loss of beneficial phytocompounds from the final product
(Raboanatahiry et al., 2021). In addition, when canola oil is heated during cooking, oxidation
and degradations of its compounds takes place. These degraded products are absorbed into
the food which then promote oxidative stress and inflammation in the body. Cold-pressing is
a method of extraction, although not commonly used, which preserves the phytonutrients in
the oil and reduces the harmful effects seen in other extraction processes (Fedko et al., 2022).

• Following a high fibre diet

Dietary fibre refers to the undigestible carbohydrates, usually polysaccharides, originating
from plant-based foods. The average adult’s diet is deficient in fibre, because of the

85
consumption of processed foods and the decreased consumption of plant-based foods. The
consumption of fibre increases gut motility, prevents constipation, assists in weight loss,
improves insulin sensitivity, promotes healthy gut microflora, reduces local and systemic
inflammation, prevents colorectal cancer, and decreases the risk of developing depression
(Barber et al., 2020). The Mediterranean diet is one example of a fibre rich diet that has been
shown to improve fertility in females partly due to its inclusion of whole grain cereals, which
have a high fibre content (Skoracka et al., 2021).

• Adequate water intake

Water is essential to life. The European Food Safety Authority defines adequate water intake
as two litres per day in females and two and a half litres per day in males (Nakamura et al.,
2020). Studies have shown that adequate water intake is necessary to improve the functions
related to cognition, weight management and the management of kidney stones (Liska et al.,
2019). There is scarce research available of the benefit of adequate water intake in the
management of female infertility.

• Eliminating alcohol
Participants recommended that patients avoid or limit alcohol intake. Alcohol has been linked
to more than 200 diseases, but its damage is usually related to how much alcohol is consumed
habitually. There have been various studies about the potential health benefits of alcohol, but
these studies do not specify a “safe” level of consumption. It has been found that even
moderate intake of alcohol can increase risk of mortality (Iranpour and Nakhaee, 2019).
Alcohol consumption has been found to increase levels of oestradiol, LH, and testosterone in
females. Binge alcohol use has also been shown to diminish ovarian reserves, decrease Anti-
Müllerian Hormone (AMH) levels and decrease chances of conception. Alcohol has shown to
negatively impact fertility in females in as little as one alcoholic drink consumed a week
(Van Heertum and Rossi, 2017).

• Eliminating/reducing caffeine
Caffeine is a central nervous system stimulant often sourced from coffee beans. It is also
commonly found in tea, energy drinks and other beverages. The side effects of caffeine intake
include irritability, anxiety, tremors, polyuria, and restlessness. More serious side effects
include arrythmias, disorientation, ischaemic disorders, hallucinations, disorientation,
seizures, and rhabdomyolysis (Evans et al., 2021). A daily dose of 400mg of caffeine a day is

86
not associated with negative side effects (Wierzejska, 2012). Caffeine intake has been
associated with an increased risk of miscarriage and ovulatory disorders, and a decrease in
chances of successful pregnancy (Cao et al., 2016; Lyngsø et al., 2017).

• Eliminating carbonated drinks

Sugar-sweetened carbonated drinks have been described as the leading source of sugar in
Western diets. They have been linked to digestive diseases, CVD, obesity, dental caries,
aggressive behaviour, and diabetes mellitus. In general, both types are linked to all-cause
mortality. These beverages are also known to increase inflammation, cause insulin resistance
and increase the risk of Parkinson’s disease (Mullee et al., 2019; Yang et al., 2017).
Machtinger et al. (2017) evaluated oocyte quality, quantity, and successful fertilisation in 359
women undergoing ART. These women were also asked to indicate their intake of carbonated
beverages. High intake of these beverages was found to decrease oocyte quality and
development and to reduce chances of successful fertilisation. This is mainly a result of the
high sugar content of these beverages.

[Link] Lifestyle modifications

The lifestyle modifications that achieved consensus in this study included eliminating
cigarette smoking, adequate sleep, and the proper management of stress.

• Eliminating cigarette smoking

Cigarette smoking is the practice of burning tobacco and drawing the smoke into the
mouth and lungs. Cigarette smoking has been linked to increased risk of coronary heart
disease, stroke, cancers of the respiratory tract, chronic obstructive pulmonary disease,
miscarriage, and poor foetal development (Adams and Morris, 2022; West, 2017).
Smoking, including second-hand smoking, has been associated with an increased
incidence of female infertility and an earlier onset of menopause. Decreased fertility has
been found in current and former smokers, particularly in women who smoke more than 10
cigarettes a day (Oboni et al., 2016; Wesselink et al., 2018).

• Adequate sleep
It has been recommended that adults sleep for at least seven to nine hours per night
(Hirshkowitz et al., 2015; Watson et al., 2015). Insufficient sleep has been associated with
fatigue, depression, and poor overall cognitive function. Prolonged sleep loss has been linked

87
to obesity, hypertension, diabetes mellitus type 2 and cardiovascular disease (Chaput et al.,
2018). Sleep deprivation is related to infertility in females due to two possible mechanisms:
interference of the HPA axis or abnormal circadian rhythms. It has also been linked to
irregular production of female sex hormones (Kloss et al., 2015; Lateef and Akintubosun,
2020; White, 2016).

• Managing stress
The term ‘stress’ refers to any stimulus, either intrinsic or extrinsic, that initiates a bodily
response. Stressful stimuli, depending on their type and severity, have been found to have
both beneficial and harmful effects. Beneficial effects are predominantly related to its aim of
preserving survival. Stress has also been linked to multiple pathologies, particularly if there is
prolonged and severe stress (Yaribeygi et al., 2017). Chronic stress is associated with CVD,
cancer, autoimmune diseases, diabetes mellitus, depression, and anxiety (Mariotti, 2015).
Stress management includes activities that improve physical, cognitive, and emotional
wellbeing under stressful circumstances. Common stress management methods include
exercise, meditation, yoga and breathing exercises (Worthen and Cash, 2021). Infertility
causes anxiety in many women, but there are conflicting views on the effect of stress on
fertility. Prolonged stress produces neuroendocrine disturbances which negatively impact
fertility. In addition, multiple studies have shown the benefit of psychological interventions to
manage stress whilst undergoing treatment for infertility (Palomba et al., 2018; Rooney and
Domar, 2018).

4.3.4 Supplementation
Participants recommended various health supplements in the management of female
infertility. The specific supplements that achieved consensus in this study included
magnesium supplements, supplements for liver support and supplements for adrenal support.

• Magnesium
Magnesium has various functions in the body, including its role in over 300 enzymatic
reactions. Hypomagnesemia is a relatively common condition and is associated with CVD,
diabetes mellitus, migraines, osteoporosis, asthma, and preeclampsia (Al Alawi et al., 2018).
The recommended daily intake of magnesium is 300-400mg per day (Razzaque, 2018).
Magnesium supplementation has been shown to improve insulin resistance in female patients
with PCOS (Porri et al., 2021).

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 • Liver support
Various recommendations were made by participants on specific supplements that are useful
to support the liver in the management of female infertility. The liver is an organ responsible
for numerous functions in the body that support processes such as detoxification, digestion,
metabolism, immune function, and vitamin storage (Kalra et al., 2022). The liver modulates
the metabolism of sex hormones and transport to tissues via SHBG. An animal study found
that in female rats, high levels of androgens which are seen in PCOS patients may promote
hepatic steatosis (Grossman et al., 2019). Participants recommended supplements to support
the liver in women undergoing treatment for infertility. These recommendations included
methylated vitamin B, DIM, sulphorophane, L-Glutathione, Rosmarinus officinalis, Carduus
marianus, Berberis vulgaris, Taraxacum officinale, and a complex of Carduus marianus,
Taraxacum officinale and Chelidonium majus. Various proprietary supplements were also
named, including AdvaClear®, Liv.52 DS, CoolBlue, LivoClear, LiverScript, Hepar
compositum, Nux Vomica Homaccord, Liva, LivoTibb, Boldocynara, DefenCELL®, and
Hormone Health. These recommendations did not achieve consensus but the supplements that
were mentioned by multiple practitioners will be discussed further.

Carduus marianus was recommended for its usefulness in supporting the liver by six
participants. Carduus marianus (milk thistle) is used for its regenerative and protective
effects on the liver as well as its anti-inflammatory, antioxidant, membrane stabilizing, and
antifibrotic properties. Carduus marianus is a well-known intervention for functional or
degenerative liver disorders. It prevents liver cirrhosis by inhibiting collagen deposition,
stimulating regeneration, and regulating cell permeability. Studies have found that the
administration of Carduus marianus reduces levels of aspartate aminotransferase (AST) and
alanine aminotransferase (ALT) (Abenavoli et al., 2018; Bahmani et al., 2015; Hellerbrand et
al., 2016). In addition, conventional drugs used for female infertility may cause ovarian
hyperstimulation syndrome (OHSS) which is associated with elevated levels of AST and
ALT, indicating the possible benefit of liver support (National Institute of Diabetes and
Digestive and Kidney Diseases, 2017).

Vitamin B complex supplements have been associated with improved fertility in females,
particularly attributed to vitamin B12 and 5-methyltetrahydrofolate (5-MTHF). Vitamin B12
deficiency has been linked to reduced fertility and poor embryo quality in patients
undergoing ART. 5-MTHF is the reduced bioactive form of folic acid. Genetic variations that

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affect the methylation of folic acid is common – this impairs an individual’s ability to convert
folic acid to methylated folate. Folate supplementation has been found to improve oocyte
quality and maturation and a folate deficiency is associated with an increased risk or neural
tube defects (Cirillo et al., 2021).

DIM was recommended by two participants. DIM is a product of indole-3 carbinol which is
found in cruciferous vegetables such as broccoli, Brussels sprouts, and cabbage (Aksu et al.,
2016). It is well-known for its preventative effects against various types of cancer
(Vermillion Maier et al., 2021). DIM has already been discussed for its usefulness in
decreasing oestrogen and increasing SHBG. DIM has also been identified as a potential
hepatoprotective agent as well as a therapeutic option in NASH (Liu et al., 2014; Tomar et
al., 2015).

Liv.52 DS was recommended by two participants. It is a supplement used to protect and

improve function of the liver and to increase appetite. It is a combination of Cichorium
intybus and Capparis spinosa (Himalaya Wellness, n.d.). A few studies have been conducted
on the usefulness of Liv.52, which have identified it as a useful hepatoprotective supplement
(Del Prete et al., 2012; Fallah Huseini et al., 2005; Vidyashankar et al., 2010).

CoolBlue is a complex of ingredients that is used to protect the liver and promote optimal
liver function that was recommended by two participants. The ingredients include Cyperi
rhizome, Pericarpium Citri Reticulatae, Fructus aurantii, Amomi fructus, Alpiniae
Katsumadai Semen, Magnoliae officinalis, Aquilariae Lignum Resinatum, Rhizoma
corydalis, Fructus Meliae Toosendan, Aucklandia lappa, Paeoniae lactiflorae, Radix
Bupleuri, Poria cocos, and Carduus marianus (Innovative Vitality, n.d.a).

LivoClear was mentioned by two participants. It is a supplement that is prescribed to protect

the liver, promote liver function, and reduce oxidative stress. Its ingredients include
Phyllanthus niruri, Picrorhiza kurroa, Andrographis paniculate, and Holarrhena
antidysenterica (MHP Vitamins, n.d.a).

LiverScript is a supplement indicated to support phases I and II of liver detoxification,

hormonal imbalances, reducing alcohol cravings, aiding in liver repair, and supporting
digestive function. It was recommended by two participants. The ingredients of LiverScript

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include Carduus marianus, Pueraria lobata, N-Acetyl-Cysteine, alpha-lipoic acid,
Taraxacum officinalis, green tea extract, and vitamin B1 (Medford, n.d.).

• Adrenal support
Various recommendations were made of specific supplements that are useful in supporting
the adrenal glands in the management of female infertility. The adrenal glands, also referred
to as the suprarenal glands, play an essential role in the body’s stress response and secrete
various hormones involved in immunity, metabolism and salt and water balance (Megha et
al., 2021). Adrenal dysfunction is associated with premature ovarian insufficiency and
decreased fertility in females (Bensing et al., 2020). Participants made specific
recommendations to support the adrenal glands including Withania somnifera, methylated
vitamin B, magnesium, vitamin B5 , gamma-aminobutyric acid (GABA), L-theanine,
adaptogens, and proprietary products including Magnol One, RE)COVER, #1 Body,
Adrenocare Formula, Adrenogen®, Adrenal Essence®, Stress-Away, Stress Relax powder,
Serenagen®, Cordyceps, Stress Damage Control™, Adreset®, Exhilarin®, Adrenal Support,
and Cortipin. It should be noted that while consensus was reached for adrenal support, these
individual supplements did not achieve consensus. The recommendations noted by multiple
participants will be discussed further.

Methylated vitamin B supplements were recommended by two participants. Vitamin B

complex supplements have been found to be effective in the management of anxiety and
depression, this is particularly related to vitamins B6 , B9 and B12 (Camfield et al., 2013;
Lewis et al., 2013). In addition, vitamin B5 (pantothenic acid) plays an essential role in
adrenal steroidogenesis and the management of long-term stress (Pan et al., 2011).

Magnesium supplementation, already discussed, was recommended by two participants for its
usefulness as a health supplement for adrenal support. In addition to the benefits already
mentioned, magnesium reduces complaints associated with mental and physical stress
because of the important role it plays in inhibiting the stress response. Magnesium deficiency
is also associated with an increased risk, and may potentially be the cause, of anxiety and
dysregulation of the HPA axis (Pickering et al., 2020; Sartori et al., 2012).

GABA is an important inhibitory neurotransmitter in the central nervous system. It was

recommended by two participants. GABA is involved in the regulation of anxiety, circadian

91
rhythms, memory, mood, and pain perception. Its pharmacological uses include anxiety,
insomnia, diabetes mellitus, hypertension, cancer, inflammation, oxidative stress, and
infection. In addition, it has been shown to have protective effects of the liver, kidneys, and
intestines. Studies have shown that the use of GABA is beneficial in improving stress and
increasing peripheral nervous system activity, with limited evidence that GABA may
improve sleep quality (Hepsomali et al., 2020; Ngo and Vo, 2019).

Magnol One was recommended by two participants. It is indicated in cases of mental

exhaustion, particularly from mental overexertion. It claims to improve mood and mental
health. Its ingredients include Magnolia officinalis and Rhodiolae roseae (Innovative Vitality,
n.d.b). Magnolia officinalis has been found to reduce stress and blood cortisol levels and to
improve various mood parameters (Talbott et al., 2013). Rhodiola rosea supports the body in
the management of the effects of stress and enhances mental performance (Li et al., 2017;
Tireki. 2021).

Adrenocare Formula was recommended by two participants. It offers endocrine support to

improve fatigue and stamina. It contains Commiphora mukul, L-tyrosine, vitamin B5 , and
potassium iodate (Nutrilife, n.d.).

4.3.5 Referrals
Various recommendations were made on referrals that may be useful in the management of
female infertility. The referrals that achieved consensus included referral to a gynaecologist,
endocrinologist, acupuncturist, reflexologist, psychologist and for ultrasound.

• Referral to a gynaecologist
Gynaecologists are physicians who specialise in female health, including surgical and
preventative health care (Tessmer-Tuck and Rayburn, 2015). Gynaecologists play an
essential role in the diagnosis, early intervention and prevention of various diseases which
may decrease female fertility (Saridogan, 2019).

• Referral to an endocrinologist
Endocrinologists are physicians who specialise in cellular communication through hormones
(Azizi, 2016). Reproductive endocrinology is a branch of endocrinology that focuses on the

92
hormones that regulate sexual function, sexual maturation, and fertility as well as disorders of
glands which affect reproductive function (Corenblum and Boyd, 2017; Andersson, 2008).

• Referral to an acupuncturist
Acupuncture is a branch of TCM that involves inserting thin needles into the skin to stimulate
underlying tissues to improve pain and tension (Patil et al., 2016). Acupuncture has been
described as a beneficial treatment in female fertility that assists in improving ovarian
function and hormonal imbalances. It has also been shown to improve chances conception in
women undergoing IVF and embryo transfer (Quan et al., 2022; Wang et al., 2021; Zhu et
al., 2018).

• Referral to a reflexologist
Reflexology is a therapeutic modality that applies pressure to reflexology areas to improve
organ function. These reflexology areas are specific areas on the hands, feet, and ears (Dalal
et al., 2014; Embong et al., 2015). There is scarce evidence available that reflexology may be
beneficial in the management of female infertility (Holt et al., 2009).

• Referral for psychological care

Psychological stress impairs fertility by increasing oxidative stress in the body thereby
impairing oocyte quality and ovarian function (Pandey et al., 2018). In addition to the effect
of stress on fertility, infertility is associated with devastating psychological and emotional
consequences (Hasanpoor-Azghdy et al., 2014). Psychology is a field of study that focuses on
behaviour and mental processes (Pérez-Álvarez, 2017). Psychotherapy is the therapy used to
manage various psychological disorders (Locher et al., 2019). Studies have shown that
psychological therapy, including cognitive behavioural therapy and support groups, improves
pregnancy rates and a sense of emotional wellbeing (Doyle and Carballedo, 2014).

• Referral for ultrasound

Ultrasound is an investigation used to produce an image of internal organs by utilising the
reflection of high frequency pulses (Whitworth et al., 2015). Ultrasound is a useful tool in
determining the cause of infertility in an individual and monitoring therapy. Common
causes of female infertility that may be viewed by ultrasound include impaired tubal
patency, pelvic masses and decreased ovarian reserve (Klenov and Van Voorhis, 2017).

93
4.4 Strengths and limitations
The various strengths and limitations pertaining to this study are discussed below.

4.4.1 Strengths
The strengths in this study were related to the platform of the questionnaire

[Link] Platform of the questionnaire

The questionnaires used in this study were created on Google Forms and sent to participants
via email. The use of an electronic questionnaires allowed participants to complete the
questionnaire at their own convenience, possibly improving response rates. The majority of
participants completed all three rounds of the study.

[Link] Anonymity
Anonymity between participants is an advantage of the Delphi technique (Boulkedid et al.,
2011; Donohoe et al., 2012; Hsu & Sandford, 2007). Anonymity was maintained throughout
this study; each participant was given a code to allow the researcher to track responses and
these codes were stored on a password protected computer. Participants were anonymous to
each other and did not have access to responses or details of other participants thereby
preventing responses being influenced by responses from other participants or concern over
other participants seeing one’s responses.

4.4.2 Limitations
The limitations in this study were related to the study sample, interventions in the third
questionnaire, access to recent studies, security and bias. The limitations associated with the
Delphi technique will also be discussed.

[Link] Study sample

The aim of this study was to gain consensus from South African homeopathic practitioners
who are considered experts in female fertility. However, many of the practitioners who were
recommended as well-known experts in the field did not respond to the invitation to
participate in the study meaning that the responses were not all from experts, but from
homeopathic practitioners who had treated female infertility in the past. The majority of the
participants were females between the ages of 45 to 54 years of age. There is no data

94
available on the ratio of male to female homeopathic practitioners in South Africa, thus it
cannot be said that the predominantly female study sample is representative of homeopathic
practitioners in the country.

[Link] Interventions in the third questionnaire

Many of the interventions listed in round two, namely specific mother tinctures,
organotherapies, gemmotherapeutics and supplements, were not included in the questionnaire
for the third round of this study. This was done to limit the length of the third questionnaire,
however this may have impacted the findings of the study as it is not known which of these
specifically named interventions would have achieved expert consensus.

[Link] Limited research in the field of complementary medicine

Research on various interventions in complementary medicine discussed in this study is
scarce. Very few studies have been done on the use of gemmotherapy, organotherapy,
nosodes, specific homeopathic remedies and complexes, and health supplements.

[Link] Security
The online platform used in this study posed a small risk in terms of privacy and security.
Although the results were stored on a password protected computer and the link for each
questionnaire was sent individually to participants, the questionnaire itself did not require a
password to complete it. This means that it is possible that the questionnaires were completed
by someone other than the intended participant, however this is highly unlikely because of
the expertise needed to complete the questionnaires.

[Link] Bias
Researcher bias was a potential limitation in this study, however attempts were made to avoid
this by submitting the first questionnaire to the University of Johannesburg to be reviewed by
the HDC and REC. All questionnaires and results were also reviewed by a supervisor. The
researcher was conscious of the importance of avoiding bias throughout this study and strived
to only facilitate the process rather than contribute to the results.

95
[Link] Limitations of the Delphi technique
The Delphi technique has conflicting views on its reliability because responses would vary
between panels of participants. It has also been criticised for forcing consensus by not
allowing participants to elaborate on their responses, however participants were given the
opportunity to do so in this study (Keeney et al., 2001).

4.5 Summary
This chapter provided a brief overview of the processes followed in this study to collect and
analyse data. It discussed the various recommendations that gained consensus in the third
round of this Delphi study. The recommendations that achieved consensus fell into various
categories: case management, homeopathic treatments, dietary recommendations, lifestyle
adjustments, supplements, and referrals. The strengths and limitations of the study were also
discussed.

96
CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS

5.1 Introduction
Chapter five presents the conclusions of this study, as well as recommendations for future
studies.

5.2 Conclusion
Infertility is a condition for which females may consider visiting a homeopath in South Africa
for various reasons. Homeopathic practitioners may use a range of interventions to manage
infertility in females including homeopathic remedies, health supplementation, dietary and
lifestyle modifications, and referral for other therapeutic interventions. The aim of this study
was to determine homeopathic practitioners’ approaches to managing female infertility in
South Africa by means of the Delphi technique.

The Delphi technique was used to establish expert consensus from South African
homeopathic practitioners who are considered knowledgeable in the management of female
infertility. A descriptive design was used, and the study was conducted in three rounds.
Twelve practitioners participated in this study, however only eleven participants completed
all three rounds. Thirty-two recommendations achieved expert consensus for their usefulness
in the management of female infertility. These recommendations were classified into the
following categories: case management, homeopathic treatments, dietary recommendations,
lifestyle adjustments, supplements, and referrals. All participants emphasised that a thorough
history taking and scheduling regular follow-up consultations should be performed in cases of
female infertility. Of the eleven participants, nine participants stated that repertorisation and
treating layer by layer are useful approaches to adopt in case analysis. The use of nosodes,
mother tinctures, gemmotherapy and organotherapy achieved consensus, with most
participants agreeing on their usefulness. All participants agreed that it is useful for patients
undergoing treatment for female infertility to increase their intake of fruits and vegetables,
eliminate or reduce processed foods, ensure adequate water intake, manage stress and get an
adequate amount of sleep. 91% of participants noted the usefulness of a high fibre diet and
the elimination or reduction of sugar and refined carbohydrates, canola oil, caffeine, and
cigarette smoking. 82% of participants agreed on the benefit of the elimination or reduction
of wheat, gluten, dairy, alcohol, and carbonated drinks as well as eating frequently
throughout the day. Regarding health supplementation, all participants agreed on the

97
importance of supplementation for adrenal support, and 82% agreed on the use of magnesium
as well as supplementation to support the liver. Most of the participants agreed on the
usefulness of referring patients with female infertility to gynaecologists, endocrinologists
(82%), acupuncturists (91%), reflexologists (82%), psychologists (91%) and for ultrasound
imaging (91%). A noteworthy point is that the homeopathic practitioners who participated in
this study appeared to adopt an individualised approach in the management of female
infertility. Each participant had their own preferences for specific homeopathic remedies,
dietary and lifestyle changes and health supplements, which was based on their own
experiences in practice.

The recommendations obtained in this study may potentially be useful to homeopathic

practitioners in the management of female infertility, in the clinical setting, however, are not
considered clinical practice guidelines, nor intended to replace individualised patient care.
The results of this study have also helped identify research gaps, which will allow for further
studies to be conducted in the field.

5.3 Recommendations
The following recommendations could be considered in future studies:
• Specific interventions mentioned in the second round were not included in the final
questionnaire and therefore consensus on these interventions could not be determined.
Future researchers could consider including all interventions obtained from previous
rounds in the final round.
• Many recommendations on therapeutic interventions were given but details regarding
dosage and frequency were not specified. Future researchers could request that
participants specify dosages of treatments prescribed so that it may be more useful in
practice.
• The link for each questionnaire was emailed to each participant but there was no
password required to complete the questionnaire. Future researchers could apply a
password to online questionnaires to ensure greater security.

98
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 APPENDIX A: Information letter

DEPARTMENT OF COMPLEMENTARY MEDICINE

RESEARCH STUDY INFORMATION LETTER
REC 11.0

01/07/2021

Good Day

My name is Robyn Anderson. I WOULD LIKE TO INVITE YOU TO PARTICIPATE in a research study on
the approach used by homeopathic practitioners in South Africa in the management of female
infertility.
Before you decide on whether to participate, I would like to explain to you why the research is being
done and what it will involve for you. I will be available to answer any questions you may have
regarding this information letter via email. The study is part of a research project being completed as
a requirement for a MHSc Complementary Medicine Degree in Homeopathy through the University
of Johannesburg.

THE PURPOSE OF THIS STUDY is to determine homeopathic practitioners’ approaches to managing

female infertility in South Africa.
Below, I have compiled a set of questions and answers that I believe will assist you in understanding
the relevant details of participation in this research study. Please read through these. If you have any
further questions I will be happy to answer them for you.

1. DO I HAVE TO TAKE PART? No, you don’t have to. It is up to you to decide to participate in the
study. I will describe the study and go through this information sheet. If you agree to take part, I
will then ask you to sign a consent form.

Participant Initials: __________

Version 3.1: Approved 26 July 2018
Author: Prof. C. Stein

149
 2. WHAT EXACTLY WILL I BE EXPECTED TO DO IF I AGREE TO PARTICIPATE? This study will consist
of a series of questionnaire. In the first questionnaire, you will be expected to relate your
particular approach to managing female infertility, based on your experience in practice. In the
second questionnaire, you will be expected to rate the importance of various interventions
identified in the first round. In the third questionnaire, you will be expected to re-evaluate the
responses you gave in the second round and will have the opportunity to change your responses
if necessary.

3. APPROXIMATELY HOW LONG WILL MY PARTICIPATION TAKE? Your participation will take
approximately 10 to 15 minutes per questionnaire, therefore approximately 45 minutes in total.

4. WHAT WILL HAPPEN IF I WANT TO WITHDRAW FROM THE STUDY? If you decide to participate,
you are free to withdraw your consent at any point up until submitting each questionnaire,
without giving a reason and without any consequences. If you wish to withdraw your consent,
you should inform me as soon as possible.

5. IF I CHOOSE TO PARTICIPATE, WILL THERE BE ANY EXPENSES FOR ME, OR PAYMENT DUE TO
ME? You will not be paid to participate in this study and you will not bear any expenses.

6. IF I CHOOSE TO PARTICIPATE, WHAT ARE THE RISKS INVOLVED? There are no anticipated risks
in this study.

7. IF I CHOOSE TO PARTICIPATE, WHAT ARE THE BENEFITS INVOLVED? There are no direct
benefits to participating in this study. This study aims to identify interventions and approaches
used by homeopathic practitioners found to be effective in managing female infertility, which
will be of value to the homeopathic profession.
8. WILL MY PARTICIPATION IN THIS STUDY BE KEPT CONFIDENTIAL? All reasonable efforts will be
made to keep your personal information confidential and respect your right to privacy. This
includes replacing your identifying personal information with a number that only I and my
research supervisor will know. You will not be identified in any research reports that are
published. Under some circumstances, such as when required to do so by a court of law, I may
have to disclose your personal information. In addition, it may happen that your information will
need to be reviewed by another organisation for quality assurance purposes. I will tell you about
this if it happens.

Participant Initials: __________

Version 3.1: Approved 26 July 2018
Author: Prof. C. Stein

150
 9. WHAT WILL HAPPEN TO THE RESULTS OF THE RESEARCH STUDY? The results will be written
into a research report that will be assessed. In some cases, results may also be published in a
scientific journal. In either case, you will not be identifiable in any documents, reports or
publications. You will be given access to the results of this if you would like to see them, by
contacting me.

10. WHAT WILL YOUR RESPONSIBILITIES BE, AS THE RESEARCHER? As the researcher, it is my
responsibility to maintain confidentiality and validity throughout the study to ensure that all
findings are reliable. I am also responsible to be available to answer any questions that you may
have at any point during the study.

11. WHO IS ORGANISING AND FUNDING THIS RESEARCH STUDY? The study is being organised by
me, under the guidance of my research supervisor at the Department of Complementary
Medicine at the University of Johannesburg. This research will be supported by the UJ
supervisor-linked bursary.

12. WHO HAS REVIEWED AND APPROVED THIS STUDY? Before this study was allowed to start, it
was reviewed in order to protect your interests. This review was done first by the Department of
Complementary Medicine, and then secondly by the Faculty of Health Sciences Research Ethics
Committee at the University of Johannesburg. In both cases, the study was approved.

13. WHAT IF THERE IS A PROBLEM? If you have any concerns or complaints about this research
study, its procedures or risks and benefits, you should ask me. You should contact me at any
time if you feel you have any concerns about being a part of this study. My contact details are:

Robyn Anderson
082 440 5245
robynanderson97@[Link]

You may also contact my research supervisor:

Dr Janice Pellow
jpellow@[Link]

Participant Initials: __________

Version 3.1: Approved 26 July 2018
Author: Prof. C. Stein

151
 If you feel that any questions or complaints regarding your participation in this study have not been
dealt with adequately, you may contact the Chairperson of the Faculty of Health Sciences Research
Ethics Committee at the University of Johannesburg:

Prof. Christopher Stein

Tel: 011 559-6564
Email: cstein@[Link]
FURTHER INFORMATION AND CONTACT DETAILS: Should you wish to have more specific
information about this research project information, have any questions, concerns or complaints
about this research study, its procedures, risks and benefits, you should communicate with me using
any of the contact details given above.
Researcher:
Robyn Anderson

Participant Initials: __________

Version 3.1: Approved 26 July 2018
Author: Prof. C. Stein
152
 APPENDIX B: Research Consent Form

DEPARTMENT OF COMPLEMENTARY MEDICINE

RESEARCH CONSENT FORM
REC 11.0

A Delphi Study on the Management of Female Infertility by Homeopathic Practitioners in South

Africa

Please initial each box below:

I confirm that I have read and understand the information letter dated 01/07/2021 for
the above study. I have had the opportunity to consider the information, ask questions and have had
these answered satisfactorily.

I understand that my participation is voluntary and that I am free to withdraw from this
study at any time without giving any reason and without any consequences to me.

I agree to participate in the above research.

_______________________ ___________________________________ ________________

Name of Participant Signature of Participant Date

_______________________ ___________________________________ ________________

Name of Researcher Signature of Researcher Date

Version 3.1: Approved 26 July 2018

Author: Prof. C. Stein

153
APPENDIX C: Responses from Round One
Q1: DESCRIBE YOUR APPROACH TO THE MANAGEMENT OF FEMALE
INFERTILITY USING HOMEOPATHIC TREATMENT IN YOUR PRACTICE
P1: Single homeopathic remedy for their emotions (starting at 200cH) (code 1.1.1)
Complexes made up specifically for the patient based on their symptoms and presenting
picture (code 1.2.1)
Herbal tincture complex, containing gemmotherapies, homeopathic remedies and
organotherapy in low potency (code 6.8.1)

P2: Identifying the central delusion (code 3.1.2)

Identifying trauma (code 3.1.2)
Identify totality of symptoms (code 3.1.2)
Identify miasm (code 3.1.2)
Identify potential hormonal contraceptives side effects (code 3.2.2)
Identify intracellular bacterial, viral and parasitic infections (code 3.2.2)
In depth homeopathic interview on mental, emotional and physical level (code 3.1.2)
Repertorisation (code 5.1.2)
Observation of body language (code 4.2)
Addressing gradually all existing layers right back to conception (code 5.2.2)
Correct homeopathic remedies (code 1.2.2)
“Prescribing nosodes for the above as the healing process unravels” (code 6.1.2)

P3: Selecting the patients simillimum remedy (code 1.1.3)

Rosmarinus mother tincture (code 6.2.3)
Silybum complex mother tincture by Mediherb for estrogen metabolism in the liver (code
6.2.3)
Rubus Idaeus gemmo (code 6.3.3)

P4: Classical Homeopathic medicines (code 1.1.4)

Constitutional case analyses (code 3.1.4)
Organ drainage in the form of mother tinctures (code 6.2.4 + 6.4.4)
If there is clearly a dysfunction on one or more organ systems then organ remedies like
liver/pancreas/ovary can be selected prior to the simillimum in treatment (code 6.5.4)

P5: Thorough past medical history regarding female reproductive concerns (code 3.2.5)
154
Repertorise which is the most appropriate remedy or remedies (code 5.1.5)
I also use mother tinctures (code 6.2.5) and gemmotherapy (code 6.3.5)
I definitely follow a more clinical approach (code 1.2.5)

P6: My approach is a clinical one (code 1.2.6)

Patients undergo a thorough case history (code 3.6)
They will get a combination script that can include a single remedy (code 1.1.6), tinctures
(code 6.2.6), organ remedies (code 6.5.6) and gemmotherapy (code 6.3.6)

P7: Constitutional remedy at a very high potency (code 1.1.7)

Herbal Agnus castus in tincture or tablet form (code 6.2.7)
Reckeweg complex R20 (no longer available but Natura make the generic) (code 6.5.7)
Acupressure daily on the ren meridian below the navel (code 6.7.7)

P7: Full history taking (code 3.8)

I regularly use mother tinctures (code 6.2.8), gemmotherapy (code 6.3.8), organ remedies
(code 6.5.8) and an appropriate single remedy (code 1.1.8) if it is clearly indicated.

I use a combination of remedies as treatment modalities. I include acupuncture (code 6.7.9).

Mainly gemmo's (code 6.3.9), organ remedies (code 6.5.9), mother tinctures (code 6.2.9) and
some single remedies (code 1.1.9) - depending on the possible cause of the infertility

I have seen results with Vitex Agnus Castus mother tincture in increasing LH and
progesterone levels (code 6.2.10)

Classical homeopathy (code 1.1.11) as well as Isotherapy (code 6.6.11), herbs (code 6.2.11)
and organ remedies (code 6.5.11).

I use a combination of classical single dose remedies (code 1.1.12), complexes (code 1.2.12)
and mother tinctures (code 6.2.12) according to the patient case

155
 Categories & Codes
1 Homeopathic Approach
1.1 Classical approach
“Single homeopathic remedy for their emotions (starting at 200cH)” (code
1.1.1)
“Selecting the patients simillimum remedy” (code 1.1.3)
“Classical Homeopathic medicines” (code 1.1.4)
“They will get a combination script that can include a single remedy” (code
1.1.6)
“Constitutional remedy at a very high potency” (code 1.1.7)
“I regularly use … an appropriate single remedy if it is clearly indicated” (code
1.1.8)
“Mainly … some single remedies - depending on the possible cause of the
infertility” (code 1.1.9)
“Classical homeopathy” (code 1.1.11)
“classical single dose remedies” (code 1.1.12)
1.2 Clinical approach
“Complexes made up specifically for the patient based on their symptoms and
presenting picture” (code 1.2.1)
“Correct homeopathic remedies” (code 1.2.2)
“I definitely follow a more clinical approach” (code 1.2.5)
“My approach is a clinical one” (code 1.2.6)
“Complexes” (code 1.2.12)
3 Thorough history taking
“Patients undergo a thorough case history” (code 3.6)
“Full history taking” (code 3.8)
3.1 Homeopathic
Identify:
• “the central delusion” (code 3.1.2)
• “past trauma” (code 3.1.2)
• “totality of symptoms” (code 3.1.2)
• “miasm” (code 3.1.2)
“In depth homeopathic interview on mental, emotional and physical level” (code
3.1.2)

156
 “Constitutional case analyses” (code 3.1.4)
3.2 Biomedical
“potential hormonal contraceptives side effects” (code 3.2.2)
“intracellular bacterial, viral and parasitic infections” (code 3.2.2)
“Thorough past medical history regarding female reproductive concerns” (code
3.2.5)
4 Physical Examination
Body language
“Observation of body language” (code 4.2)
5 Case Analysis
5.1 Repertorisation
“In depth homeopathic … repertorisation” (code 5.1.2)
“Repertorise which is the most appropriate remedy or remedies” (code 5.1.5)
5.2 Treating layer by layer
“Addressing gradually all existing layers right back to conception” (code 5.2.2)
6 Multiple Therapeutic Interventions
6.1 Nosodes
“Prescribing nosodes for the above as the healing process unravels” (code
6.1.2)
6.2 Mother tinctures
“Rosmarinus mother tincture” (code 6.2.3)
“Silybum mother tincture by Mediherb for oestrogen metabolism in the liver”
(code 6.2.3)
“I also use mother tinctures…” (code 6.2.5)
“They will get a combination script that can include … tinctures” (code 6.2.6)
“Herbal Agnus castus in tincture or tablet form” (code 6.2.7)
“I regularly use mother tinctures” (code 6.2.8)
“Mainly mother tinctures … depending on the possible cause of the infertility”
(code 6.2.9)
“Vitex Agnus Castus mother tincture in increasing LH and progesterone levels.”
(code 6.2.10)
“Herbs” (code 6.2.11)
“Mother tinctures” (code 6.2.12)
6.3 Gemmotherapy

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 “Rubus Idaeus gemmo” (code 6.3.3)
“I also use … gemmotherapy” (code 6.3.5)
They will get a combination script that can … gemmotherapy” (code 6.3.6)
“I regularly use … gemmotherapy” (code 6.3.8)
“Mainly gemmo's … depending on the possible cause of the infertility” (code
6.3.9)
6.4 Organ drainage
“Organ drainage in the form of mother tinctures” (code 6.4.4)
6.5 Organotherapy
“If there is clearly a dysfunction on one or more organ systems then organ
remedies like liver/pancreas/ovary can be selected prior to the simillimum in
treatment” (code 6.5.4)
“They will get a combination script that can include … organ remedies” (code
6.5.6)
“Reckeweg complex R20 (no longer available but Natura make the generic)”
(code 6.5.7)
“I regularly use … organ remedies” (code 6.5.8)
“Mainly organ remedies … depending on the possible cause of the infertility”
(code 6.5.9)
“Organ remedies” (code 6.5.11)
6.6 Isotherapy
“Isotherapy” (code 6.6.11)
6.7 Acupuncture
“Acupressure daily on the ren meridian below the navel” (code 6.7.7)
“I include acupuncture” (code 6.7.9)
6.8 Herbal complexes
“Herbal tincture complex, containing gemmotherapies, homeopathic remedies
and organotherapy in low potency” (code 6.8.1)

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Q2: DESCRIBE YOUR APPROACH TO THE MANAGEMENT OF FEMALE
INFERTILITY USING DIETARY AND LIFESTYLE RECOMMENDATIONS
Increase vegetables to 6 portions a day (code 2.1.1)
Eat at least 2 portions of fruit a day (code 2.1.1)
Cut out wheat (code 2.1.1) alcohol (code 2.2.1) caffeine (code 2.2.1) sugar (code 2.1.1) and
smoking (code 3.6.1)
Increase sleep to at least 8 hours (code 3.1.1)
Manage stress (code 3.2.1)

Individualized anti-mould diet according to the metabolic type and microbiological terrain
(code 2.1.2)
No alcohol (code 2.2.2), coffee (code 2.2.2), ordinary tea (code 2.2.2), cold drinks (code
2.2.2), energy drinks (code 2.2.2), tap water (code 2.2.2), fasting (code 2.1.2), gluten (code
2.1.2), dairy (code 2.1.2), sugar (code 2.1.2), soy (code 2.1.2), vinegar (code 2.1.2), processed
foods (code 2.1.2), margarine (code 2.1.2), canola oil (code 2.1.2), chewing gums (code
2.1.2), artificial sweeteners (code 2.2.2)
No smoking (code 3.6.2), recreational drugs (code 3.6.2), hormonal contraceptives (code
4.4.2), vaccines (code 4.4.2)
Use radiation protection devices (code 4.3.2)
De-worming every 3 months with herbal parasite formulae (code 4.4.2)
Vaginal steaming (code 3.4.2)
Apply correct genital hygiene (code 3.4.2)
Improving sex life (code 3.3.2)
Using natural insect repellents instead of naphthalene (code 4.3.2)
Use fluoride free toothpaste (code 3.4.2), non-alcoholic mouthwash (code 3.4.2), insulating
thatch roofs (code 4.3.2)
Resolve any damp/mould exposure (code 4.3.2)
Regular maintenance of all air conditioners (code 4.3.2)
Regular pest control (code 4.3.2)
Specialized blood, urine and stool tests for identifying various pathogens causing infertility
(code 1.1.2-1.3.2)
Regular follow ups, changing the potency or the remedy as needed (code 4.1.2)

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Stabilise blood sugar through limitation of refined wheat (code 2.1.3), alcohol (code 2.2.3),
coffee (code 2.2.3) and sugar (code 2.1.3)
Eat 3-5 meals a day (code 2.1.3)
Avoid exceeding a 14 hour overnight fast (code 2.1.3)
Nutrient dense high fibre diet (code 2.1.3)
Breathing and relaxation techniques (code 3.2.3)
Sleep hygiene (code 3.1.3)
If unresponsive to the initial protocol: The use of gene profiling through GENEWAY to map
the patients individual hormone metabolism pathways (code 1.4.3)
Blood tests on day 3 and 21 of menstrual cycle (if roughly 28 day cycle) (code 1.1.3)

Thorough analysis of diet and nutrition

Patient's nutritional status is usually addressed prior to homeopathic treatment or concurrently
Avoid inflammatory inducing foods (code 2.1.4)
Avoid junk foods (code 2.1.4)
Increase fruit and vegetable intake (code 2.1.4)
1 week food detoxes with fruits and vegetables can also be indicated in certain patients to
promote detoxification through the gut prior to treatment (code 2.1.4)

Ensure that the patient is aware of xeno-oestrogens (code 2.1.5)

Avoid animal protein that is not free range (code 2.1.5)
Increase intake of vegetables of all colours (code 2.1.5) and especially cruciferous vegetables
to enhance antioxidant activity (code 2.1.5)
Limit/exclude caffeine (code 2.2.5)
Increase water consumption (code 2.2.5)
Drink green tea twice daily (code 2.2.5)

Ensure patients are following a moderate and healthy diet and lifestyle
Limit coffee to around 1-2 cups at most (code 2.2.6)
Drink 2-3 litres of water a day (code 2.2.6)
Eat 2-3 seasonal fruits a day (code 2.2.6)
No real limitation in quantity of vegetables (code 2.1.6)
Exclude red meat, maximum 1 serving a week of organic, free-range red meat (code 2.1.6)
No alcohol (code 2.2.6)

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Wheat products to be reduced or cut out completely especially in ladies with PCOS or insulin
resistance (code 2.2.6)
Refined sugars are also cut out or severely reduced (code 2.2.6)
Patients should exercise (30min of moderate exercise 3-5 x a week). As long as their exercise
is not extreme enough to impact their cycles, they continue. Exercise can include cardio,
weight training, yoga, pilates etc. (code 3.5.6)
Medicines may be changed or repeat at their follow up - roughly 3-4 weeks time (code 4.1.6)

Exercise daily (code 3.7)

Predominantly plant-based diet (code 2.1.7)
Continue treatment for at least 6 months before reviewing the script (code 4.3.7)

It is very important to manage insulin levels in some patients with infertility and with others
to advise around avoiding food allergens (code 2.1.8) or unhealthy food choices (code 2.1.8)
Generally a low glycaemic diet is advised with no refined carbohydrates (code 2.1.8)
I generally advise avoiding gluten (code 2.1.8) and excessive dairy (code 2.1.8), sugar (code
2.1.8) and caffeine (code 2.2.8)
Adequate water intake is also important (code 2.2.8)
Assessment on Biores electroacupuncture device (code 1.5.8)

Depends on the patient's existing diet: I usually reduce dairy (code 2.1.9), increase plant
proteins (code 2.1.9), also increase the vegetable and fruit intake (code 2.1.9). Exercise (not
too little, not too much) is important (code 3.5.9) and definitely stress reduction techniques
(code 3.2.9)

Minimizing sugar (code 2.1.10), refined carbohydrates (code 2.1.10) and red meat (code
2.1.10) in the diet reduces blood glucose and insulin levels in women diagnosed with
Polycystic ovarian syndrome
Increasing cruciferous vegetable consumption (code 2.1.10) to as frequently as possible
reduces symptoms of estrogen dominance, however, this is not always viable as many women
experience severe digestive discomfort from these
'Eating the rainbow' i.e. eating a variety of different coloured whole foods (fruits, vegetables,
proteins, unsaturated fats) at each meal improves nutrient status and general health (code
2.1.10)

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Exercising 3-5 times a week for 30 minutes reduces stress levels, a well-known cause of
infertility (code 3.5.10)

Stress management (code 3.2.11), exercise (code 3.5.11), alkaline diet (code 2.1.11) with low
carbs (code 2.1.11), medium fat (code 2.1.11) and medium protein (code 2.1.11).

I advise patients to cut out coffee (code 2.2.12), gluten (code 2.1.12), sugar (code 2.1.12) and
dairy (code 2.1.12), increase exercise as applicable (code 3.5.12), and stress management
techniques (code 3.2.12)

Categories & Codes

1 Special Investigations
1.1 Blood tests
“Specialized blood… tests for identifying various pathogens causing infertility”
(code 1.2)
“Blood tests on day 3 and 21 of menstrual cycle” (if roughly 28 day cycle) (code
1.3)
1.2 Urine tests
“Specialized … urine … tests for identifying various pathogens causing
infertility” (code 1.2)
1.3 Stool tests
“Specialized … stool tests for identifying various pathogens causing infertility”
(code 1.2)
1.4 Gene profiling
“If unresponsive to the initial protocol: The use of gene profiling through
GENEWAY to map the patients individual hormone metabolism pathways” (code
1.3)
1.5 Biores electroacupuncture device
“Assessment on Biores electroacupuncture device” (code 1.5.8)
2 Dietary Adjustments
2.1 Food
Fruit and Vegetables
“Increase vegetables to 6 portions a day” (code 2.1.1)
“Eat at least 2 portions of fruit a day” (code 2.1.1)

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“Increase fruit and vegetable intake” (code 2.1.4)
“1 week food detoxes with fruits and vegetables can also be indicated in certain
patients to promote detoxification through the gut prior to treatment” (code
2.1.4)
“Increase intake of vegetables of all colours” (code 2.1.5)
“Eat cruciferous vegetables to enhance antioxidant activity” (code 2.1.5)
“No real limitation in quantity of vegetables” (code 2.1.6)
“Predominantly plant-based diet” (code 2.1.7)
“Increase plant proteins” (code 2.1.9)
“Increase the vegetable and fruit intake” (code 2.1.9)
“Increasing cruciferous vegetable consumption to as frequently as possible
reduces symptoms of estrogen dominance” (code 2.1.10)
“'Eating the rainbow' i.e. eating a variety of different coloured whole foods
(fruits, vegetables, proteins, unsaturated fats) at each meal improves nutrient
status and general health” (code 2.1.10)
Wheat
“Cut out wheat” (code 2.1.1)
“Stabilise blood sugar through limitation of refined wheat” (code 2.1.3)
“Wheat products to be reduced or cut out completely especially in ladies with
PCOS or insulin resistance” (code 2.1.6)
“no gluten” (code 2.1.2)
“I generally advise avoiding gluten” (code 2.1.8)
“I advise patients to cut out gluten” (code 2.1.12)
Sugar
“Cut out sugar” (code 2.1.1)
“No sugar” (code 2.1.2)
“Stabilise blood sugar through limitation of sugar” (code 2.1.3)
“Refined sugars are also cut out or severely reduced” (code 2.1.6)
“I generally advise avoiding sugar” (code 2.1.8)
“Minimizing sugar reduces blood glucose and insulin levels in women diagnosed
with Polycystic ovarian syndrome” (code 2.1.10)
“I advise patients to cut out sugar” (code 2.1.12)
Fat
“medium fat“ (code 2.1.11)

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Protein
“medium protein” (code 2.1.11)
Dairy
“no dairy” (code 2.1.2)
“I generally advise avoiding excessive dairy” (code 2.1.8)
“Reduce dairy” (code 2.1.9)
“I advise patients to cut out dairy” (code 2.1.12)
Meal Frequency
“no fasting” (code 2.1.2)
“Eat 3-5 meals a day” (code 2.1.3)
“Avoid exceeding a 14 hour overnight fast” (code 2.1.3)
Carbohydrates
“Generally a low glycaemic diet is advised with no refined carbohydrates” (code
2.1.8)
“Minimizing refined carbohydrates in the diet reduces blood glucose and insulin
levels in women diagnosed with Polycystic ovarian syndrome” (code 2.1.10)
“low carbs” (code 2.1.11)
Soy
“no soy” (code 2.1.2)
Meat
“Avoid animal protein that is not free range” (code 2.1.5)
“Exclude red meat, maximum 1 serving a week of organic, free-range red meat”
(code 2.1.6)
“Minimizing red meat in the diet reduces blood glucose and insulin levels in
women diagnosed with Polycystic ovarian syndrome” (code 2.1.10)
Xenoestrogens
“Ensure that the patient is aware of xeno-oestrogens” (code 2.1.5)
Processed foods
“no processed foods” (code 2.1.2)
“no margarine” (code 2.1.2)
Vinegar
“no vinegar” (code 2.1.2)
Canola Oil
“no canola oil” (code 2.1.2)

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 Fibre
“Nutrient dense high fibre diet” (code 2.1.3)
Other
“no chewing gum” (code 2.1.2)
“Avoid inflammatory inducing foods” (code 2.1.4)
“Avoid junk foods” (code 2.1.4)
“Avoiding food allergens” (code 2.1.8)
“Avoiding unhealthy food choices” (code 2.1.8)
“Alkaline diet” (code 2.1.11)
2.2 Drinks
Water
“No tap water” (code 2.2.2)
“Increase water consumption” (code 2.2.5)
Drink 2-3 litres of water a day (code 2.2.6)
“Adequate water intake is also important” (code 2.2.8)
Alcohol
“Cut out alcohol” (code 2.2.1)
“No alcohol” (code 2.2.2)
“Stabilise blood sugar through limitation of alcohol” (code 2.2.3)
“No alcohol” (code 2.2.6)
Coffee/Tea
“Cut out caffeine” (code 2.2.1)
“No coffee” (code 2.2.2)
“No ordinary tea” (code 2.2.2)
“Stabilise blood sugar through limitation of coffee” (code 2.2.3)
“Limit/exclude caffeine” (code 2.2.5)
“Drink green tea twice daily” (code 2.2.5)
“Limit coffee to around 1-2 cups at most” (code 2.2.6)
“I generally advise avoiding caffeine” (code 2.2.8)
“I advise patients to cut out coffee” (code 2.2.12)
“No artificial sweeteners” (code 2.2.2)
Carbonated Drinks
“No cooldrinks” (code 2.2.2)
“No energy drinks” (code 2.2.2)

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3 Lifestyle Adjustments
3.1 Sleep
“Increase sleep to at least 8 hours” (code 3.1.1)
“Sleep hygiene” (code 3.1.3)
3.2 Stress management
“Manage stress” (code 3.2.1)
“Breathing and relaxation techniques” (code 3.2.3)
“Definitely stress reduction techniques” (code 3.2.9)
“Stress management” (code 3.2.11)
“stress management techniques” (code 3.2.12)
3.3 Relationships
“Improving sex life” (code 3.3.2)
3.4 Personal Hygiene
“vaginal steaming” (code 3.4.2)
“Apply correct genital hygiene” (code 3.4.2)
“Use fluoride free toothpaste” (code 3.4.2)
“Use non-alcoholic mouthwash” (code 3.4.2)
3.5 Exercise
“Patients should exercise (30min of moderate exercise 3-5 x a week). As long as
their exercise is not extreme enough to impact their cycles, they continue.
Exercise can include cardio, weight training, yoga, pilates etc.” (code 3.5.6)
“Exercise daily” (code 3.5.7)
“Exercise (not too little, not too much) is important” (code 3.5.9)
“Exercising 3-5 times a week for 30 minutes reduces stress levels, a well-known
cause of infertility” (code 3.5.10)
“Exercise” (code 3.5.11)
“increase exercise as applicable” (code 3.5.12)
3.6 Addictive substances
“Cut out smoking” (code 3.6.1)
“No smoking” (code 3.6.2)
“No recreational drugs” (code 3.6.2)
4 Case Management
4.1 Regular follow-up consultations
“Regular follow ups, changing the potency or the remedy as needed” (code

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 4.1.2)
Medicines may be changed or repeat at their follow up - roughly 3-4 weeks time
(code 4.1.6)
4.2 Duration of treatment
“Continue treatment for at least 6 months before reviewing the script” (code
4.2.7)
4.3 Environmental factors
“Use radiation protection devices” (code 4.3.2)
“Using natural insect repellents instead of naphthalene” (code 4.3.2)
“Use insulating thatch roofs” (code 4.3.2)
“Resolve any damp/mould exposure” (code 4.3.2)
“Regular maintenance of all air conditioners” (code 4.3.2)
“Regular pest control” (code 4.3.2)
4.4 Medication
“no hormonal contraceptives” (code 4.4.2)
“no vaccines” (code 4.4.2)
“De-worming every 3 months with herbal parasite formulae” (code 4.4.2)

DESCRIBE YOUR APPROACH TO THE MANAGEMENT OF FEMALE INFERTILITY

USING HEALTH SUPPLEMENTS

Multivitamin (code 1.1)

Vitamin B complex – methylated (code 2.1)
If further supplements are required then testing for basic vitamin deficiencies are done i.e. vit
d, vit b12, etc (code 3.1)

Individualized supplements (code 3.2) and Chinese medicines (code 4.2) according to the
metabolic type, microbiological terrain and TCM pattern

A good multivitamin (code 1.3) containing methylated B vitamins (code 2.3), selenium (code
5.3), iodine (code 6.3) and zinc (code 7.3).
Support oestrogen metabolism with methylated B Vitamins (code 2.3), DIM (by Xymogen:
Hormone protect) (code 8.3)
Progesterone support with Chaste tree by Mediherb (code 9.3)
Nourishing of polyfollicular/PCOS pattern with Polyfem by Mediherb (code 3.3)
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TCM (traditional Chinese medicine) approach to organ imbalances using Nourish root yin;
Nourish blood; Expel Uterus stagnation (code 4.3)

The use of supplementation is based on need/requirement (code 3.4)

If a patient has PCOS/insulin resistance, then cinnamon (code 3.4) or berberine
herbs/supplements (code 3.4) can be useful.
Vitamin Deficiencies can be determined on blood work with the appropriate interventions
made (code 3.4).

The supplements that I use for each patient will be different based on what their specific area
of concern (via what their blood tests show on day 22 of their cycle). I do not believe in
protocol medicine and will prescribe specifically for each case (code 3.5)

Over the counter prenatal vitamins and minerals (code 1.6)

Coenzyme Q10/Ubiquinol (code 10.6)
Omega 3 (code 11.6)
N-acetyl cysteine (code 12.6)
Inositol (code 13.6)
DIM (code 8.6)
Supplements are condition dependent, as well as must also be in line with affordability for the
patient (code 3.6)

Folic acid (code 2.7)

Prenatal vitamin (code 1.7)
Omega complexes (code 11.7)

I will advise supplementation depending on what has come up as deficient or lacking during
the consultation or findings on the bloods (code 3.8)
Iron may be necessary in iron deficiency anaemia (code 3.8)
Chromium or Berberine is important in insulin resistance, weight management or metabolic
syndrome hindering fertility (code 3.8)
Vitamin B (code 2.8), Magnesium (code 14.8) or stress management supplements are often
necessary.

Use these as well, again depending on the patient's needs (code 3.9)
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Femiscript (Medford) reduces elevated FSH levels in women following cessation of the OCP
(code 3.10)
Femiscript (Medford) elevates progesterone levels in women with low LH and progesterone
levels (code 3.10)
PCOSITOL™ (Delfran) reduces LH, testosterone and insulin levels in women diagnosed with
polycystic ovarian syndrome (code 3.10)
DIM (Di-indolemethane) reduces the estrogen to progesterone ratio, as seen on day 21 bloods,
in women with estrogen dominance (code 3.10)

This is dependent on the cause of the infertility i.e if there is insulin-resistance and PCOS then
INSUMAX (code 3.11), Inositol (code 3.11), Omega 3 (code 3.11), liver support (code 3.11).
Adrenal support is also often needed (code 3.11). If menstrual irregularities or Estrogen
dominance then I will use Renewed Balance progesterone cream (code 3.11) and Omega 6
(code 3.11)

I evaluate the use of health supplements according to each case. Most patients I see are
already on heaps of supplements.

Categories & Codes

1 Multivitamin
“Multivitamin” (code 1.1)
“A good multivitamin containing methylated B vitamins, selenium, iodine and zinc”
(code 1.3)
“Over the counter prenatal vitamins and minerals” (code 3.6)
“Prenatal vitamin” (code 1.7)
2 Vitamin B
“Vitamin B complex – methylated” (code 2.1)
“A good multivitamin containing methylated B vitamins” (code 2.3)
“Support oestrogen metabolism with methylated B Vitamins” (code 2.3)
“Folic acid” (code 3.7)
“Vitamin B … supplements are often necessary” (code 2.8)
3 Individualised Supplements for the treatment of a specific condition or deficiency
PCOS/Insulin Resistance

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“Nourishing of polyfollicular/PCOS pattern with Polyfem by Mediherb” (code 3.3)
“If a patient has PCOS/insulin resistance, then cinnamon (code 3.4) or berberine
herbs/supplements” (code 3.4)
“Chromium or Berberine is important in insulin resistance, weight management or
metabolic syndrome hindering fertility” (code 3.8)
“if there is insulin-resistance and PCOS then INSUMAX” (code 3.11)
“if there is insulin-resistance and PCOS then Inositol” (code 3.11)
“if there is insulin-resistance and PCOS then Omega 3” (code 3.11)
“if there is insulin-resistance and PCOS then liver support” (code 3.11)
“if there is insulin-resistance and PCOS then adrenal support is often needed.” (code
3.11)
“PCOSITOL™ (Delfran) reduces LH, testosterone and insulin levels in women
diagnosed with polycystic ovarian syndrome” (code 3.10)
Vitamin Deficiency
Vitamin Deficiencies can be determined on blood work with the appropriate
interventions made (code 3.4).
“The supplements that I use for each patient will be different based on what their
specific area of concern (via what their blood tests show on day 22 of their cycle). I do
not believe in protocol medicine and will prescribe specifically for each case” (code
3.5)
“I will advise supplementation depending on what has come up as deficient or lacking
during the consultation or findings on the bloods” (code 3.8)
“Iron may be necessary in iron deficiency anaemia” (code 3.8)
Oestrogen Dominance
“DIM (Di-indolylmethane) reduces the oestrogen to progesterone ratio, as seen on day
21 bloods, in women with oestrogen dominance” (code 3.10)
“If menstrual irregularities or oestrogen dominance then I will use Renewed Balance
progesterone cream” (code 3.11)
“If menstrual irregularities or oestrogen dominance then I will use Omega 6” (code
3.11)
Contraceptive Effects
“Femiscript (Medford) reduces elevated FSH levels in women following cessation of the
OCP” (code 3.10)
Other

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 “Individualized supplements according to the metabolic type, microbiological terrain
and TCM pattern” (code 3.2)
“Femiscript (Medford) elevates progesterone levels in women with low LH and
progesterone levels” (code 3.10)
4 Chinese Medicines
“Chinese medicines according to the metabolic type, microbiological terrain and TCM
pattern” (code 4.2)
“TCM (traditional Chinese medicine) approach to organ imbalances using Nourish root
yin; Nourish blood; Expel Uterus stagnation” (code 4.3)
5 Selenium
“A good multivitamin containing … selenium” (code 5.3)
6 Iodine
“A good multivitamin containing … iodine” (code 6.3)
7 Zinc
“A good multivitamin containing … zinc” (code 7.3)
8 Diindolylmethane (DIM)
“Support oestrogen metabolism with … DIM (by Xymogen: Hormone protect)” (code
8.3)
“DIM” (code 8.6)
9 Vitex Agnus Castus
“Progesterone support with Chaste tree by Mediherb” (code 9.3)
10 Ubiquinol
“Coenzyme Q10/Ubiquinol” (code 10.6)
11 Omega Oils
“Omega 3” (code 11.6)
“Omega complexes” (code 11.7)
12 N-Acetyl Cysteine
“N-acetyl cysteine “(code 12.6)
13 Inositol
“Inositol” (code 13.6)
14 Magnesium
“Magnesium … supplements are often necessary” (code 14.8)

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DO YOU USE, OR REFER PATIENTS FOR, ANY OTHER FORMS OF TREATMENT FOR
FEMALE INFERTILITY?

IVF (code 1.1)

ICSI (code 1.1)
Gynaecological exams for infertility check-ups (code 4.1)

Live blood analysis (code 4.2)

Craniosacral therapy (code 3.2)
Acupuncture (code 2.2)
Chiropractic (code 2.2)
Osteopathy (code 2.2)
Postural integration (code 3.2)
Physiotherapy (code 1.2)
DNAlysis (code 4.2)
Family constellations (code 3.2)
Iridology (code 4.2)
Specialized blood, urine and stool tests for identifying various pathogens causing infertility
(code 4.2)
Chinese medicines according to the metabolic type, microbiological terrain and TCM pattern
(code 4.2)

Ultrasound (code 4.3)

Hysterosalpingogram (code 4.3)
If unresponsive to the initial protocol: The use of gene profiling through GENEWAY to map
the patients individual hormone metabolism pathways (code 4.3)
Blood tests on day 3 and 21 of menstrual cycle (if roughly 28 day cycle) (code 4.3)
TCM (traditional Chinese medicine) approach to organ imbalances using Nourish root yin;
Nourish blood; Expel Uterus stagnation (code 4.3)

Gynaecological assessment using transvaginal ultrasound (code 4.4) for determining any
underlying factors related to infertility
Endocrinologist referrals might also be necessary if indicated (code 1.4)

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If the patient is approaching 39/40 years of age and they have no children, I will make them
aware of the various fertility clinics so that they too can make an informed choice as to what
treatment options are available (code 1.5)
Blood tests to assess endocrine dysfunction and inflammatory concerns (code 4.5)

Chinese medicine (code 2.6)

Acupuncture (code 2.6) Patients may have an acupuncture treatment 2-4 x a month.
When necessary, I refer patients to fertility specialists for further investigations and
management. I try to maintain contact with those patients as the combined treatment is
beneficial (code 1.6, code 4.6)
Refer to a psychologist when I can see the conception process is taking a toll on the patient or
when they have a history that may be a hinderance to them getting pregnant. Maybe their
relationship is rocky and they need therapy to assist. Trying to conceive can be a very
emotionally difficult time (code 5.6)
Day 3 blood test, sometimes also a day 21 test (code 4.6)

If after six months there is no pregnancy I would refer for a gynaecological exam (code 4.7)

Reflexology (code 3.8), acupuncture (code 2.8), psychotherapy for the emotional support or
stress management (code 5.8), nutritionist or dietician if dietary guidelines I have made are
not sufficient in getting the results we desire (code 1.8).
Last resort is fertility treatment should we not succeed (code 1.8)
Blood tests to decide on most appropriate approach (code 4.8)

Acupuncture (code 2.9)

Reflexology (code 3.10)

I do ultrasounds (code 4.12), biopuncture (code 2.12), refer for assisted reproduction if
necessary (code 1.12). I work closely with some reproductive endocrinologists (code 1.12).

1 Conventional Treatments
“IVF” (code 1.1)
“ICSI” (code 1.1)

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 “Physiotherapy” (code 1.2)
“Endocrinologist referrals might also be necessary if indicated” (code 4.4)
“If the patient is approaching 39/40 years of age and they have no children, I will
make them aware of the various fertility clinics so that they too can make an
informed choice as to what treatment options are available” (code 1.5)
“When necessary, I refer patients to fertility specialists for further investigations
and management. I try to maintain contact with those patients as the combined
treatment is beneficial” (code 1.6)
“nutritionist or dietician if dietary guidelines I have made are not sufficient in
getting the results we desire” (code 1.8)
“Last resort is fertility treatment should we not succeed” (code 1.8)
“I refer for assisted reproduction if necessary” (code 1.12)
“I work closely with some reproductive endocrinologists.” (code 1.12)
2 Other Complementary Medicine modalities, registered under AHPCSA
“Acupuncture” (code 2.2)
“Chiropractic” (code 2.2)
“Osteopathy” (code 2.2)
“Chinese medicine” (code 2.6)
“Acupuncture - patients may have an acupuncture treatment 2-4 x a month” (code
2.6)
“Acupuncture” (code 2.8)
“Acupuncture” (code 2.9)
“I do biopuncture” (code 2.12)
3 Alternative Therapies, not registered under AHPCSA
“Craniosacral therapy” (code 3.2)
“Postural integration” (code 3.2)
“Family constellations” (code 3.2)
“Reflexology” (code 3.8)
“Reflexology” (code 3.10)
4 Special Investigations
“Gynaecological exams for infertility check-ups” (code 4.1)
“Live blood analysis” (code 4.2)
“DNAlysis” (code 4.2)
“Iridology” (code 4.2)

174
 “Specialized blood, urine and stool tests for identifying various pathogens causing
infertility” (code 4.2)
“Ultrasound” (code 4.3)
“Hysterosalpingogram” (code 4.3)
“If unresponsive to the initial protocol: The use of gene profiling through
GENEWAY to map the patients individual hormone metabolism pathways” (code
4.3)
“Blood tests on day 3 and 21 of menstrual cycle” (if roughly 28 day cycle) (code
4.3)
“Gynaecological assessment using transvaginal ultrasound for determining any
underlying factors related to infertility” (code 4.4)
“Blood tests to assess endocrine dysfunction and inflammatory concerns” (code
4.5)
“When necessary, I refer patients to fertility specialists for further investigations
and management. I try to maintain contact with those patients as the combined
treatment is beneficial” (code 4.6)
“Day 3 blood test, sometimes also a day 21 test” (code 4.6)
“If after six months there is no pregnancy I would refer for a gynaecological
exam” (code 4.7)
“Blood tests to decide on most appropriate approach” (code 4.8)
“I do ultrasounds” (code 4.12)
5 Psychological Care
“Refer to a psychologist when I can see the conception process is taking a toll on
the patient or when they have a history that may be a hinderance to them getting
pregnant. Maybe their relationship is rocky and they need therapy to assist. Trying
to conceive can be a very emotionally difficult time” (code 4.6)
“psychotherapy for the emotional support or stress management”(code 5.8)

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APPENDIX D: Analysis of responses from round two
Statements

Somewhat Important
Not recommended
When treating female infertility, the following

Very Important

Median (IQR)
Unimportant
are…

Essential
Single homeopathic remedy 0 1 4 4 3 4 (1)
Homeopathic complexes 0 1 4 6 1 4 (1)
Thorough history taking 0 0 0 1 11 5 (0)
Repertorisation 0 1 5 1 5 3.5(2)
Regular follow-Ups 0 0 1 2 9 5 (1)
Treating layer by layer 0 3 2 2 5 4 (3)
Nosodes 0 4 5 1 2 3 (1)
Mother tinctures 0 2 4 5 1 3.5(1)
Gemmotherapy 0 5 4 2 1 3 (1)
Organotherapy 0 2 8 1 1 3(0)
Biopuncture 0 5 6 1 0 3 (1)
Organ drainage 0 6 4 2 0 2.5(1)

The number and percentage of participants that selected the following nosodes for
female infertility is:
• Carcinosin (n = 3; 25%) in 200cH and 10M, Folliculinum (n = 2; 16.7%) in
30cH, 12X and 200cH, Medorrhinum (n = 2; 16.7%) in 200cH and 10M,
Syphilinum (n = 1; 8.3%), Thyroideum (n = 1; 8.3%) in 9cH and 30cH, Variolinum
200cH (n = 1; 8.3%)
The number and percentage of participants that selected the following organotherapies
for female infertility is:
• Folliculinum (n = 5; 41.7%) in 7cH and 200cH, adrenal gland (n = 4;
33.3%), ovary (n = 3, 25%), thyroid (n = 2; 16.7%), liver (n = 2; 16.7%),
progesterone (n = 2; 16.7%), oestrogen (n = 2; 16.7%) in 4cH, 7cH and 9cH,
testosterone (n = 1, 8.3%), uterus (n = 1; 8.3%), fallopian tube (n = 1; 8.3%),
pituitary gland (n = 3; 25%), endometrium (n = 2; 16.7%), Heel Ovarium
compositum (n = 1; 8.3%), Heel Hormeel (n = 1; 8.3%), Dr Reckeweg R20 (n = 1;
8.3%)
176
The number and percentage of participants that selected the following biopuncture
injections for female infertility is:
• Ovarium compositum (n = 3; 25%) over the ovaries; Hepar compositum (n
= 1; 8.3%), Thyreoidea compositum (n = 2; 16.7%), Coenzyme compositum (n =
1; 8.3%), Lymphomyosot (n = 1; 8.3%)
The number and percentage of participants that selected the following organ drainage
remedies for female infertility is:
• Berberis vulgaris (n = 1; 8.3%), Rosmarinus officinalis (n = 1; 8.3%),
Silybum marianum (n = 1; 8.3%), complex of Carduus marianus, Taraxacum
officinalis and Chelidonium majus (n = 1; 8.3%), Carduus marianus (n = 1; 8.3%),
Taraxacum officinalis (n=1; 8.3%), Heel Nux Vomica Homaccord (n = 1; 8.3%),
Heel Lymphomyosot (n = 1; 8.3%), Heel Berberis-Homaccord (n = 1; 8.3%)
The number and percentage of participants that selected the following mother tinctures
for female hormonal disorders is:
• Vitex agnus-castus (n = 11; 91.7%), Glycyrrhiza glabra (n = 2; 16.7%),
Angelica sinensis (n = 2; 16.7%), Actaea racemose (n = 4; 33.3%), Thuja
occidentalis (n = 1; 8.3%), Carduus marianus (n = 1; 8.3%), Asparagus
racemosus (n = 1; 8.3%), Paeonia lactiflora (n = 1; 8.3%), Eleutherococcus
senticosus (n = 1; 8.3%), Rhodiola rosea (n = 1; 8.3%), Panax ginseng (n = 1;
8.3%), Humulus lupulus (n = 1; 8.3%), Calendula officinalis (n = 1; 8.3%),
Angelica archangelica (n = 1; 8.3%)
The number and percentage of participants that selected the following
gemmotherapeutics for female hormonal disorders is:
• Rubus ideaus (n = 4; 33.3%), Vaccinium vitis-idaea (n = 2; 16.7%), Tilia
tomentosa (n = 1, 8.3%), Ribes nigrum (n = 1, 8.3%), Viburnum opulus (n = 1;
8.3%), Juniperus communis (n = 1; 8.3%)
The number and percentage of participants that selected the following mother tinctures
for female infertility related to impaired adrenal function is:
• Withania somnifera (n = 7; 58.3%), Glycyrrhiza glabra (n = 6; 50%),
Scutellaria lateriflora (n = 1; 8.3%), Panax ginseng (n = 5; 41.7%), Valeriana
officinalis (n = 1; 8.3%), Passiflora incarnata (n = 2; 16.6%), Eleutherococcus
senticosus (n = 2; 16.6%), Rhodiola rosea (n = 4; 33.3%), Schisandra chinensis
(n = 1; 8.3%), Ginkgo biloba (n = 1; 8.3%), Cordyceps (n = 1; 8.3%), Vitex agnus-
castus (n = 2; 16.7%)

177
The number and percentage of participants that selected the following
gemmotherapeutics for female infertility related to impaired adrenal function is:
• Ribes nigrum (n = 4; 33.3%), Tilia tomentosa (n = 1; 8.3%), Rubus ideaus
(n = 1; 8.3%)
The number and percentage of participants that selected the following mother tinctures
for female infertility related to thyroid disorders is:
• Withania somnifera (n = 4; 33.3%), Fucus vesiculosus (n = 3; 25%),
Bacopa monnieri (n = 1; 8.3%), Glycyrrhiza glabra (n = 1; 8.3%)
The number and percentage of participants that selected the following
gemmotherapeutics for female infertility related to thyroid disorders is:
• Rubus ideaus (n = 1; 8.3%)

Statements

Somewhat Important
Not recommended
When treating female infertility, it should be

Very Important

Median (IQR)
Unimportant
recommended to…

Essential
Increase fruit & vegetable intake 0 0 0 5 7 5(1)
Eliminate/reduce wheat & gluten 0 0 5 4 3 4(1)
Eliminate/reduce sugar & refined carbohydrates 0 0 2 5 5 4(1)
Eliminate/reduce dairy 0 0 5 5 2 4(1)
Eat frequently throughout the day 0 0 6 4 2 3.5(1)
Minimise soy products 0 1 7 3 1 3(1)
Eliminate/reduce red meat 0 2 7 2 1 3(0)
Eliminate/reduce vinegar 0 8 3 0 1 2(1)
Eliminate/reduce processed foods 0 0 0 8 4 4(1)
Eliminate/reduce canola oil 0 2 3 4 3 4(1)
High fibre diet 0 0 4 4 4 4(2)
Adequate water intake 0 0 0 2 10 5(0)
Eliminate alcohol 0 0 2 5 5 4(1)
Eliminate/reduce caffeine 0 0 4 4 4 4(2)
Eliminate carbonated drinks 0 0 2 4 6 4.5(1)
Eliminate cigarette smoking 0 0 0 2 10 5(0)
Adequate sleep 0 0 0 3 9 5(1)

178
Manage stress 0 0 0 3 9 5(1)
Avoid vaccinations 1 1 4 2 4 3.5(2)
Radiation protection devices 0 2 7 1 2 3(0)
Vaginal steaming 2 6 2 0 2 2(1)
Correct genital hygiene 1 1 4 3 3 3.5(1)
Non-alcoholic mouthwash 2 6 2 1 1 2(1)
Fluoride-free toothpaste 2 4 5 0 1 2.5(1)

The number and percentage of participants that selected the following advice regarding
fruit & vegetable intake for female infertility is:
• Fruits & vegetables on the low glycaemic list (n = 2; 16.7%), plant-based
diet (n = 2; 16.7%), 2-6 portions of vegetables a day (n = 3; 25%), 2-3 portions of
fruit a day (n = 3; 25%), mostly cooked vegetables (n = 1; 8.3%), a lot of green
vegetables (n = 1; 8.3%), eat a range of colourful fruits and vegetables (n = 3;
25%), limit bananas and potatoes (n = 1; 8.3%), eat raw fruits and vegetables (n
= 1; 8.3%), cruciferous vegetables (n = 2; 16.7%)

Statements
Somewhat Important
Not recommended

When treating female infertility, the following Very Important

Median (IQR)
Unimportant

supplements are…
Essential

A multivitamin 0 1 6 4 1 3(1)
Vitamin B supplement 0 0 6 3 3 3.5(1)
Iodine supplement 2 1 9 0 0 3(1)
Zinc supplement 0 1 10 1 0 3(0)
Coenzyme Q10/Ubiquinol 1 0 8 3 0 3(0)
N-Acetyl Cysteine 1 2 7 2 0 3(1)
Magnesium supplement 0 0 5 5 2 4(1)
Selenium supplement 1 0 6 4 1 3(1)
Omega 3 supplement 0 0 3 5 4 4(2)

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Statements

Somewhat Important
Not recommended
When treating female infertility related to

Very Important

Median (IQR)
Unimportant
PCOS, the following supplements are…

Essential
Cinnamon supplement 0 2 3 5 2 4(1)
Berberine supplement 0 0 1 8 3 4(0)
Chromium supplement 0 2 3 6 1 4(1)
Inositol 0 1 0 7 4 4(1)
Liver support 0 0 1 6 5 4(1)
Adrenal support 0 0 1 5 6 4.5(1)

The number and percentage of participants that selected the following treatments for
liver support for female infertility is:
• Metagenics AdvaClear® (n = 1; 8.3%), Himalaya Liv 52 DS (n = 2;
16.7%), Panaxea International CoolBlue (n = 2; 16.7%), Panaxea International
LivoClear (n = 2; 16.7%), Methylated vitamin B (n = 1; 8.3%), diindolylmethane (n
= 2; 16.7%), sulphorophane (n = 1; 8.3%), Medford LiverScript (n = 2; 16.7%),
Heel Hepar compositum (n = 1; 8.3%), Heel Nux Vomica Homaccord (n = 1;
8.3%), Natura Liva (n = 1; 8.3%); Tibb LivoTibb (n = 1; 8.3%), Rosmarinus
officinalis (n = 1; 8.3%), Silybum marianum (n = 2; 16.7%), complex of Carduus
marianus, Taraxacum officinalis and Chelidonium majus (n = 1; 8.3%), A. Vogel
Boldocynara (n = 1; 8.3%), Carduus marianus (n = 4; 33.3%), Berberine vulgaris
(n = 1; 8.3%), Taraxacum officinalis (n = 1; 8.3%), L-Glutathione (n = 1; 8.3%),
Cell-Logic DefenCELL® (n = 1; 8.3%), Hormone Health (n = 1; 8.3%)

The number and percentage of participants that selected the following treatments for
adrenal support for female infertility is:
• Withania somnifera (n = 1; 8.3%), Panaxea International Magnol One (n =
2; 16.7%), Panaxea International RE)COVER (n = 1; 8.3%), Panaxea
International #1 Body (n = 1; 8.3%), Adrenocare (n = 2; 16.7%), Metagenics
Adrenogen® (n = 1; 8.3%), methylated vitamin B (n = 2; 16.7%), magnesium (n =
2; 16.7%), vitamin B5 (n = 1; 8.3%), Xymogen Adrenal Essence® (n = 1; 8.3%),
Medford Adrenal Support (n = 1; 8.3%), Tibb Stress-Away (n = 1; 8.3%), gamma-
180
 Aminobutyric acid (n = 2; 16.7%), L-theanine (n = 1; 8.3%), Idexis Stress Relax
powder (n = 1; 8.3%), Metagenics Serenagen® (n = 1; 8.3%), adaptogens (n = 1;
8.3%), Idexis Cortipin (n = 1; 8.3%), Idexis Cordyceps (n = 1; 8.3%), Solal Stress
Damage Control™ (n = 1; 8.3%), Metagenics Adreset® (n = 1; 8.3%),
Metagenics Exhilarin® (n = 1; 8.3%)

Statements

Somewhat Important
Not recommended
When treating female infertility related to

Very Important

Median (IQR)
Unimportant
oestrogen dominance, the following

Essential
supplements are…

Diindolylmethane (DIM) 1 0 2 3 6 4.5(2)

Omega 6 supplement 1 4 5 2 0 3(1)

The number and percentage of participants that selected the following treatments for
female infertility related to oestrogen dominance is:
• Eliminate hormone replacement therapy (n = 1; 8.3%), methylated B
vitamins (n = 1; 8.3%), sulphoraphane (n = 2; 16.7%), Vitex agnus-castus (n = 2;
16.7%), Angelica sinensis (n = 1; 8.3%), Tribulus terrestris (n = 1; 8.3%), Indole-
3-carbinol (n = 1; 8.3%), diindolylmethane (n = 1; 8.3%), liver support (n = 1;
8.3%), increasing fibre in the diet (n = 1; 8.3%), lignans (n = 1; 8.3%), resistant
starch (n = 1; 8.3%), treating low progesterone (n = 1; 8.3%), AIM Renewed
Balance progesterone cream (n = 1; 8.3%), support Phase 2 detox, manage
cycle and dysmennorhoea using constitutional homeopathy (n = 1; 8.3%)
Statements
Somewhat Important
Not recommended

When treating female infertility, referral for the

Very Important

Median (IQR)
Unimportant

following is…
Essential

IVF or ICSI 2 1 3 3 3 3.5(2)

Gynaecologist 0 0 2 4 6 4.5(1)
Endocrinologist 1 1 4 4 2 3.5(1)

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Dietician/Nutritionist 1 0 5 4 2 3.5(1)
Acupuncture 0 1 3 3 5 4(2)
Chiropractic 1 2 4 2 3 3(2)
Osteopathy 1 3 3 2 3 3(2)
Chinese medicine 1 1 1 6 3 4(1)
Craniosacral therapy 1 2 4 2 3 3(2)
Family constellations 3 3 4 1 1 2.5(2)
Reflexology 0 0 7 2 3 3(1)
Iridology 2 4 4 0 2 2.5(1)
Psychological care 1 0 4 3 4 4(2)

Statements

Somewhat Important
Not recommended
When treating female infertility, referral for the

Very Important

Median (IQR)
Unimportant
following is…

Essential
Live blood analysis 2 6 3 0 1 2(1)
DNA analysis 0 0 9 1 2 3(0)
Ultrasound 0 1 1 4 6 4.5(1)

The number and percentage of participants that selected the following blood tests for
female infertility is:
• Thyroid function and antibodies (n = 8; 66.7%), vitamin D3 (n = 6; 50%),
oestrogen/E2 (n = 6; 50%), follicle stimulating hormone (n = 5; 41.7%), luteinising
hormone (n = 5; 41.7%), prolactin (n = 5; 41.7%), progesterone (n = 4; 33.3%),
testosterone (n = 4; 33.3%), dehydroepiandrosterone (n = 4; 33.3%), liver
function test (n = 3; 25%), insulin (n = 3; 25%), iron studies (n = 3; 25%), high-
sensitivity C-reactive protein (n = 3; 25%), cortisol (n = 3; 25%), full blood count
(n = 3; 25%), homocysteine (n = 2; 16.7%), anti-mullerian hormone (n = 2;
16.7%), glucose (n = 2; 16.7%), lipogram (n = 2; 16.7%), magnesium (n = 1;
8.3%), urea & electrolytes (n = 1; 8.3%), urate (n = 1; 8.3%), haemoglobin A1C
(n = 1; 8.3%), lipoprotein a (n = 1; 8.3%), vitamin B12 (n = 1; 8.3%), amylase (n =
1; 8.3%), lipase (n = 1; 8.3%), D-dimer (n = 1; 8.3%), food screen (n = 1; 8.3%),
Borrelia Western Blot (n = 1; 8.3%), CD57 count (n = 1; 8.3%), kryptopyrrols (n =

182
1; 8.3%), Coxsackie B antibodies (n = 1; 8.3%), Hepatitis B surface antigens (n =
1; 8.3%), Hepatitis C antibodies (n = 1; 8.3%), Epstein-Barr virus antibodies (n =
1; 8.3%), cytomegalovirus antibodies (n = 1; 8.3%), herpes antibodies (n = 1;
8.3%), sexually transmitted disease screen with or without HIV (n = 1; 8.3%),
anti-streptolysin O (n = 1; 8.3%), anti-deoxyribonuclease B (n = 1; 8.3%), brucella
antibodies (n = 1; 8.3%), rickettsia antibodies (n = 1; 8.3%), Q fever antibodies (n
= 1; 8.3%), chlamydia antibodies (n = 1; 8.3%), mycoplasma antibodies (n = 1;
8.3%), bartonella antibodies (n = 1; 8.3%), bilharzia antibodies (n = 1; 8.3%), H.
pylori antigens (n = 1; 8.3%), heavy metals condensed (n = 1; 8.3%),
androstenedione (n = 1; 8.3%), infertility screen (n = 1; 8.3%), MTHFR PCR (n =
1; 8.3%)

183
APPENDIX E: Analysis of responses from round three
Statements

Level of Agreement (%)

Number of Participants
Strongly disagree

Strongly agree

Median (IQR)
When treating female infertility, it is

Disagree

Unsure

Agree
important to…

A. Therapeutic Interventions
Use a single homeopathic remedy 0 3 0 5 3 72.7 (8) 4 (3)
Use homeopathic complexes 1 2 0 6 2 72.7 (8) 4 (2)
Perform thorough history taking 0 0 0 0 11 100 (11) 5 (0)
Repertorise 0 1 1 5 4 81.8 (9) 4 (1)
Schedule regular follow-Ups 0 0 0 4 7 100 (11) 5 (1)
Treat layer by layer 0 0 2 4 5 81.8 (9) 4 (1)
Use nosodes 0 1 0 5 5 90.9 (10) 4 (1)
Use mother tinctures 0 0 1 6 4 90.9 (10) 4 (1)
Use gemmotherapy 0 0 1 7 3 90.9 (10) 4 (1)
Use organotherapy 0 1 0 6 4 90.9 (10) 4 (1)
Use biopuncture 0 1 4 3 3 54.5 (6) 4 (2)
Use organ drainage 0 1 3 4 3 63.6 (7) 4 (2)
B. Dietary and Lifestyle Modifications
Increase fruit & vegetable intake 0 0 0 5 6 100 (11) 5 (1)
Eliminate/reduce wheat & gluten 0 0 2 3 6 81.8 (9) 5 (1)
Eliminate/reduce sugar & refined
0 0 1 3 7 90.9 (10) 5 (1)
carbohydrates
Eliminate/reduce dairy 0 1 1 3 6 81.8 (9) 5 (1)
Eat frequently throughout the day 0 0 2 5 4 81.8 (9) 4 (1)
Minimise soy products 0 1 2 5 3 72.7 (8) 4 (2)
Eliminate/reduce red meat 0 2 4 2 3 45.5 (5) 3 (2)
Eliminate/reduce vinegar 1 1 6 1 2 27.3 (3) 3 (1)
Eliminate/reduce processed foods 0 0 0 4 7 100 (11) 5 (1)
Eliminate/reduce canola oil 0 0 1 3 7 90.9 (10) 5 (1)
Consume a high fibre diet 0 0 1 5 5 90.9 (10) 4 (1)

184
Ensure adequate water intake 0 0 0 0 11 100 (11) 5 (0)
Eliminate alcohol 0 0 2 1 8 81.8 (9) 5 (1)
Eliminate/reduce caffeine 0 0 1 5 5 90.9 (10) 4 (1)
Eliminate carbonated drinks 0 0 2 2 7 81.8 (9) 5 (1)
Eliminate cigarette smoking 0 0 1 1 9 90.9 (10) 5 (0)
Ensure adequate sleep 0 0 0 1 10 100 (11) 5 (0)
Manage stress 0 0 0 0 11 100 (11) 5 (0)
Avoid vaccinations 0 1 2 2 6 72.7 (8) 5 (2)
Use radiation protection devices 1 1 3 2 4 54.5 (6) 4 (2)
Undergo vaginal steaming 0 1 7 2 1 27.3 (3) 4 (1)
Maintain correct genital hygiene 0 0 3 4 4 72.7 (8) 4 (2)
Use non-alcoholic mouthwash 0 1 4 4 2 54.5 (6) 4 (1)
Use fluoride-free toothpaste 1 0 4 5 1 54.5 (6) 4 (1)
C. Supplementation
Take a multivitamin 0 1 3 3 4 63.6 (7) 4 (2)
Take a vitamin B supplement 0 0 3 6 2 72.7 (8) 4 (1)
Take an iodine supplement 0 2 6 2 1 27.3 (3) 3 (1)
Take a zinc supplement 0 1 3 5 2 63.6 (7) 4 (1)
Take coenzyme Q10/Ubiquinol 0 0 5 5 1 54.5 (6) 4 (1)
Take N-Acetyl Cysteine 0 2 5 3 1 36.4 (4) 3 (1)
Take a magnesium supplement 0 1 1 4 5 81.8 (9) 4 (1)
Take a selenium supplement 0 1 2 6 2 72.7 (8) 4 (1)
Take an omega 3 supplement 0 0 3 3 5 72.7 (8) 4 (2)
Supplementation for PCOS
Take a cinnamon supplement 0 2 5 3 1 36.4 (4) 3 (1)
Take a berberine supplement 0 1 3 3 4 63.6 (7) 4 (2)
Take a chromium supplement 0 2 3 4 2 54.5 (6) 4 (1)
Take inositol 0 1 3 3 4 63.7 (7) 4 (2)
Use liver support 0 1 1 5 4 81.8 (9) 4 (1)
Use adrenal support 0 0 0 6 5 100 (11) 4 (1)
Supplementation for Oestrogen Dominance
Take diindolylmethane (DIM) 0 1 2 1 7 72.7 (8) 5 (2)
Take an omega 6 supplement 0 7 1 1 2 27.3 (3) 2 (2)
D. Referrals
185
Refer for IVF or ICSI 0 3 4 3 1 36.4 (4) 3 (2)
Refer to a gynaecologist 0 0 1 4 6 90.9 (10) 5 (1)
Refer to an endocrinologist 0 0 2 7 2 81.8 (9) 4 (0)
Refer to a dietician/nutritionist 0 3 3 4 1 45.5 (5) 3 (2)
Refer for acupuncture 0 1 0 6 4 90.9 (10) 4 (1)
Refer to a chiropractor 0 3 5 2 1 27.3 (3) 3 (2)
Refer for osteopathy 0 3 4 3 1 36.4 (4) 3 (2)
Refer for Chinese medicine 0 2 2 4 3 63.7 (7) 4 (2)
Refer for craniosacral therapy 0 2 3 4 2 54.5 (6) 4 (1)
Refer for family constellations 0 3 4 3 1 36.4 (4) 3 (2)
Refer for reflexology 0 1 1 7 2 81.8 (9) 4 (0)
Refer for iridology 0 4 2 3 2 45.5 (5) 3 (2)
Refer for psychological care 0 1 0 6 4 90.9 (10) 4 (1)
Refer for live blood analysis 0 7 2 1 1 18.2 (2) 2 (1)
Refer for DNA analysis 0 2 1 5 3 72.7 (8) 4 (2)
Refer for ultrasound 0 0 1 4 6 90.9 (10) 5 (1)

186
APPENDIX F: REC clearance letter

FACULTY OF HEALTH SCIENCES

RESEARCH ETHICS COMMITTEE

NHREC Registration: REC 241112-035

ETHICAL CLEARANCE LETTER

(RECX 2.0)

Student/Researcher Robyn Anderson Student Number 216019080

Name

Supervisor Name Pellow, Janice

Department Homoeopathy

A DELPHI STUDY ON THE MANAGEMENT OF FEMALE INFERTILITY

Research Title
BY HOMEOPATHIC PRACTITIONERS IN SOUTH AFRICA

Date 17 June 2021 Clearance Number REC-1094-2021

Approval of the research proposal with details given above is granted, subject to any conditions
under 1 below, and is valid until 2022/06/16.

1. Conditions:
Gatekeeper permission, as required.

2. Renewal:
It is required that this ethical clearance is renewed annually, within two weeks of the date
indicated above. Renewal must be done using the Ethical Clearance Renewal Form (REC 10.0),
to be completed and submitted to the Faculty Administration office. See Section 12 of the REC
Standard Operating Procedures.

187
3. Amendments:
Any envisaged amendments to the research proposal that has been granted ethical clearance must
be submitted to the REC using the Research Proposal Amendment Application Form (REC 8.0)
prior to the research being amended. Amendments to research may only be carried out once a
new ethical clearance letter is issued. See Section 13 of the REC Standard Operating Procedures.

4. Adverse Events, Deviations or Non-compliance:

Adverse events, research proposal deviations or non-compliance must be reported within the
stipulated time-frames using the Adverse Event Reporting Form (REC 9.0). See Section 14 of the
REC Standard Operating Procedures.

The REC wishes you all the best for your studies.

Yours sincerely.

RECX 2.0 – Faculty of Health Sciences

Research Ethics Committee

188
APPENDIX I: Turnitin report

191
APPENDIX J: Ethical clearance renewal letter

FACULTY OF HEALTH SCIENCES

RESEARCH ETHICS COMMITTEE

NHREC Registration: REC 241112-035

ETHICAL CLEARANCE RENEWAL LETTER

(RECX 3.0)

Student/Researcher Anderson, R Student Number 216019080

Name

Supervisor Name Dr J Pellow Co-Supervisor -

Name

Department Complementary Medicine

A DELPHI STUDY ON THE MANAGEMENT OF FEMALE INFERTILITY

Research Title
BY HOMEOPATHIC PRACTITIONERS IN SOUTH AFRICA

Previous Clearance Date 17 June 2021 Clearance Number REC-1094-2021

Date 26 May 2022

Approval of the research with details given above is renewed and is valid until 26 May 2023.

1. Conditions:
None.

2. Renewal:
It is required that this ethical clearance is renewed annually, within two weeks of the date
indicated above. Renewal must be done using the Ethical Clearance Renewal Form (REC 10.0),
to be completed and submitted to the Faculty Administration office. See Section 12 of the REC
Standard Operating Procedures.

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3. Amendments:
Any envisaged amendments to the research proposal that has been granted ethical clearance must
be submitted to the REC using the Research Proposal Amendment Application Form (REC 8.0)
prior to the research being amended. Amendments to research may only be carried out once a
new ethical clearance letter is issued. See Section 13 of the REC Standard Operating Procedures.

4. Adverse Events, Deviations or Non-compliance:

Adverse events, research proposal deviations or non-compliance must be reported within the
stipulated time-frames using the Adverse Event Reporting Form (REC 9.0). See Section 14 of the
REC Standard Operating Procedures.

The REC wishes you all the best for your studies.

Yours sincerely.

Prof. Christopher Stein

Chairperson: REC

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ANNEXURE 1: Round 1 questionnaire

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ANNEXURE 2: Round 2 questionnaire

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ANNEXURE 3: Round 3 questionnaire

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