BIOETHICS IN INFERTILITY MANAGEMENT IN THE MUSLIM WORLD
by G I Serour, FRCOG, FRCS

Bioethics is the study of ethical issues arising in health care and the biological sciences. It also includes the study of social, legal and economic matters related to these ethical issues. There are different modalities available for the treatment of infertility for both the male and the female partners depending upon the cause of the infertility. Some of these modalities had been practised for hundreds of years and never were of ethical concern: medical therapy, hormonal therapy, corrective and reconstructive surgery for male or female infertility are some of these modalities. These treatments were not of major ethical concern because they did not separate the bonding of the sexual act from the process of reproduction. Reproduction was only possible when both partners practised the act of sexual intercourse for months or years after undergoing these treatments. However, since the birth of the first test tube baby, Louise Brown, in England in 1978 (1), medically assisted conception (MAC) has evoked great interest among the public as well as in the medical profession. Couples for the first time became able to have children without having sexual intercourse. This new type of treatment for infertility has created a great ethical debate all over the world among different societies and the followers of different religions. MAC involving a third party by providing an egg, a sperm or a uterus provoked even more debate, disagreement and controversy.

The origin of MAC or artificial reproduction began with attempts to fertilize human oocytes outside the body. Although mammalian oocytes were fertilized extracorporeally at the end of the last century (2), in vitro fertilization of human oocytes was accomplished only in 1944 by Rook and Menkin (3). Further experimentation in the handling of human gametes led to the various techniques of MAC available today.

There are different techniques of artificial reproduction, for example in vivo artificial reproduction where fertilization of the husbands' and wives' gametes occurs within the body of the wife, in vitro artificial reproduction where fertilization of the gametes is extracorporeal and artificial reproduction involving a third party.

For each type of MAC there are different approaches. Pregnancy and childbirth had been achieved through in vivo fertilization by different procedures; intrauterine insemination (IUI), intratubal insemination (ITI), gamete intrafallopian transfer (GIFT), fallopian replacement of eggs with delayed intrauterine insemination (FREDI), and peritoneal oocyte and sperm transfer (POST) (4-8).

Pregnancy and childbirth have also been achieved by different techniques involving extracorporeal fertilization namely in vitro fertilization and embryo transfer (IVF & ET), pronuclear-stage tubal transfer (PROST), zygote intrafallopian transfer (ZIFT), and tubal embryo stage transfer (TEST) (19-16).

More recently pregnancy and childbirth have been reported after micromanipulation techniques including partial zone drilling (PZD), subzonal sperm injection (SUZI), and finally intracytoplasmic sperm injection (ICSI). Micromanipulation using spermatid cells has also been reported to produce pregnancy and childbirth (17-21).

Though MAC was originally introduced as an additional line of treatment of female infertility caused by tubal damage, it was extended to include the treatment of unexplained infertility and mild to moderate forms of male infertility. Indications for MAC have changed recently. The tremendous success which can be achieved with ICSI, whether using ejaculated sperm or surgically retrieved sperm, has made MAC important for treatment of male infertility.

MAC involving a third party has also resulted in pregnancy and childbirth by using both in vivo and in vitro fertilization techniques. The contribution of the third party is by providing a sperm cell, an egg, an embryo or even a uterus to carry the baby until it is born (22-28).

Reproductive choice in medically assisted conception:

It is the right of the person to choose freely his or her reproductive performance including his or her reproductive potential. Though reproductive choice is basically a personal decision, it is not totally so. This is because reproduction is a process which involves not only the person who makes the choice, but it also involves the other partner, the family, society and the world at large. It is therefore not surprising that reproductive choice is affected by the diverse contexts, sexual morals, cultures and religions, as well as the official stance of different societies.

The reproductive choice of the person not uncommonly conflicts with the views of his or her own society. This is likely to occur when his or her choice does not have the approval and support of the society. Not all societies permit all forms of MAC (29). Every day many people cross national borders to fulfil a reproductive choice which may not be permitted in their own societies or countries. Such acts are by no means restricted to one country or to followers of one religion. That many Muslims fly to Europe or the United States to fulfil a reproductive choice, which they cannot have in their own country, is a well-known fact for physicians working in the field of assisted conception. The same behaviour also exists in Europe among residents of some European countries who have restricted the access to MAC. The recent birth of a baby to a postmenopausal British woman who had medically assisted conception in Italy made news all over the world.

Islam, background and medically assisted conception

In 1992 Islam had over 1.250 billion followers (30). With the present rate of population growth it is expected that Muslims will increase to 2.5 billion by the year 2020 (31). The teaching of Islam covers all fields of human activity: spiritual and material, individual and social, educational and cultural, economic and political, national and international (32). Instructions which regulate everyday life and to be adhered to by good Muslims are called Sharia. There are two sources of Sharia in Islam: primary and secondary. The primary sources of Sharia in chronological order are:

1. The Holy Qur'an, the very word of God.
2. The Sunna and Hadith, which are the authentic traditions and sayings of the Prophet Mohamed (Peace be upon him) as collected by specialists in Hadith.
3. Igmaah, which is the unanimous opinion of Islamic scholars or Aimma.
4. Analogy (Kias), which is the intelligent reasoning used to rule on events, not mentioned by the Qur'an and Sunna, by matching against similar or equivalent events already ruled on.

A good Muslim resorts to the secondary sources of Sharia in matters not dealt with in the primary sources. The secondary sources of Sharia are Istihsan, which is the choice of one of several lawful options, views of the Prophet's companions; current local customs if lawful, public welfare, and rulings of previous divine religions if they do not contradict the primary sources of Sharia.

The Sharia classifies all human actions without exception into one of five categories: obligatory, as fasting and praying; recommended, as marriage and family formation; permitted, as breaking a fast when sick or travelling; disapproved, but not forbidden, as divorce; and absolutely forbidden, as killing.

Even if the action is forbidden, it may be undertaken if the alternative would cause harm. The Sharia is not rigid. It is flexible enough to adapt to emerging situations in different times and places. It can accommodate different honest opinions so long as they do not conflict with the spirit of its primary sources and are directed to the benefit of humanity (32).

MAC was not mentioned in the primary sources of Sharia. However, these same sources have affirmed the importance of marriage; family formation and procreation (33, 37). In Islam adoption is not acceptable as a solution to the problem of infertility (38).

In Islam infertility and its treatment with the unforbidden is allowed and encouraged. It is essential if it involves the preservation of procreation and treatment of infertility in one partner of the married couple (39). This applies to MAC which is one line of treatment of infertility. The modern techniques of MAC, including micromanipulation of the oocyte to facilitate fertilization, are no exceptions. The prevention and treatment of infertility are of particular significance in the Muslim world. The social status of the Muslim woman, her dignity, her self-esteem and her place in the family and society as a whole are closely related to her procreation. Childbirth and child rearing are regarded as family commitments and not just as biological and social functions.

Need for MAC in the Muslim world

Although estimates of the prevalence of infertility are not very accurate and vary from region to region, approximately 8-10% of couples experience some form of infertility problem. When extrapolated to the global population, this means that 50-80 million people may be suffering from infertility (40 - 41). It is believed that 29-44 million of these infertile couples are Muslims because of a relatively high prevalence of infertility, 10-15%, among Muslims in developing countries (42, 44). The rate of tubal occlusion in sub-Saharan Africa with its predominant Muslim population, is over three times that in other regions, with the exception of the Eastern Mediterranean (41). All the developing countries, where most of the Muslim population is located, had rates of tubal infertility higher than those in the developed ones. The patterns of male infertility are less clear, but regional variation is seen in the rates of varicocele and accessory gland infection (41). MAC is among the different therapeutic measures, available today, for couples with tubal or male infertility. Sometimes MAC is the only available method for the treatment of these conditions. The choice of treatment available to the couple and for their physician is governed by the availability of the method, success rate, implications and complications involved, cost, and social, legal and ethical aspects of artificial reproduction.

The first four factors interact and affect directly or indirectly the last group of factors. The success rate of artificial reproduction is of particular importance because of the misconceptions which the public not uncommonly has about the results of the technique, being misled by the mass media and dishonest claims.

Bioethics in medically assisted conception

Any debate on the social, legal and ethical issues surrounding MAC must consider these new techniques within the general context of reproductive health care. In providing this new technology one must respect the dignity of human beings, security of human genetic material, inviolability of the person, inalienability of the person and the necessary quality of services. These principles demand a measure of protection for the human embryo that is consistent with national, cultural, religious and social traditions. Ethical discourse is necessary for societies to develop and form their responses to any scientific or medical innovation (45).

The four ethical principles are the traditional principles of justice, autonomy (respect for persons), beneficence (duty to do good) and nonmaleficence (avoidance of harm). There are two ethical levels concerned: the micro-ethical and macro-ethical. The micro-ethical level applies to relations between individuals. The macro-ethical level applies to relationships with the community, and between communities and their members (46).

Also, there are three moral principles which provide an ethical basis for artificial reproduction. The principle of liberty, which guarantees a right to freedom of action; the principle of utility, which defines moral rightness by the greatest good for the greatest number; and the principle of justice, which requires that everyone have equal access to necessary goods and services. However, one must remember that ethics and morality are only valid when individuals can act freely. Medical ethics are based on the moral, religious, philosophical ideals and principles of the society in which they are practised (47). It is therefore not surprising to find that what is ethical in one society might not be considered ethical in another. It is mandatory for the practising physicians, and critics of conduct, to be aware of such backgrounds before they make their judgement on medical practice (48). The ethical attitude of the individual is coloured by the attitude of the society, which reflects the interest of theologians, demographers, family planning administrators, physicians, policy makers, sociologists, economists and legislators. Responsible policy makers in the medical profession in each country have to decide on what is ethically acceptable in their own country; guided by the international guidelines, which should be tailored to suit their own society. Truly ethical conduct consists of personal searching for relevant values that lead to an ethically inspired decision (49). Those for whom religion is important, and it is for the Muslims, need to distinguish between medical ethics and humanitarian considerations on the one hand, and religious teachings and national laws on the other. The physician also has to be concerned about the legality of his acts which are undertaken on the basis of ethical precepts.

Bioethics of medically assisted conception practice in the Muslim world

Islam enjoins the purity of genes and heredity and so to avoid mixing genes is a basic principle. It deems that each child should relate to a known father and mother. Adoption is not allowed, as it implies deceit, hiding from children their true genetic lineage and heredity. Based on the opinions accepted in the Islamic world, and relying on the Views of Fuqaha'a, physicians, ethicists, lawyers and specialists, one may conclude the following:

1. Screening of potential candidates for utilisation of MAC:
   Physicians should limit access to MAC to where clinical circumstances do not present significant risks to potential offspring. This should be on the grounds of conscience and medicine and not on any social discrimination (50).
2. Since marriage is a contract between the wife and husband during the span of their marriage, no third party should intrude into the marital functions of sex and procreation (39, 50-54).
3. A third party is not acceptable whether he or she provides a sperm, an egg, an embryo or a uterus (50).
4. If the marriage contract has come to an end because of divorce or death of the husband, artificial reproduction cannot be performed on the female partner even using sperm cells from the former husband (39,43,50-54).
5. Cryopreservation; the excess number of fertilized eggs (pre-embryo) can be preserved by cryopreservation. The frozen pre-embryo is the property of the couple alone and may be transferred to the same wife in a successive cycle but only during the validity of the marriage contract (50).
6. Multifetal pregnancy reduction; multifetal pregnancy reduction is only allowed if the prospect of carrying the pregnancy to viability is very small. It is also allowed if the life or health of the mother is in jeopardy (50-55-58).
7. Surrogate motherhood; in the Islamic World surrogacy is forbidden, although at one time it was allowed (51).

Pregnancy after the menopause

Medically assisted conception may enable post-menopausal women to become pregnant and have children. Pregnancy after the menopause appeals to the egalitarians as it is fair for old women to have children as older men have always been able to father children. However, the issue is not that simple. Men are not so directly involved in the process of pregnancy and childbirth and to a great extent in the process of mothering the new born child, at least in the first few months of life, as women are. Such physiological processes no doubt tax and exhaust the health reserves of women far more than those of men. Also pregnancy in the post-menopause may be unjust to the child as it violates the right of the newly born child to get his or her adequate share of love, care and tenderness provided by younger mothers. These are all practical reasons against pregnancy after the change of life but there are ethical issues too.

Pregnancy in the post-menopause using donated eggs is ethically unacceptable in the Muslim World. Apart from bringing in outside genes it exposes mothers to increased maternal risks and complications and is unfair to the newly born child. Pregnancy after the post-menopause using the parents' frozen embryos is associated with increased maternal risks and needs further evaluation.

Bioethics of medically assisted conception research in the Muslim World

Embryo Research:

The main ethical concern has been the alleged immorality of using embryos for research purposes. However, embryo research has non-procreative interests, which include improvement of knowledge in the treatment of infertility, improvement of contraception, treatment and prevention of cancer, and treatment and prevention of birth defects.

Embryo research denigrates the importance of human life by treating embryos as a means rather than an end. Embryo research could harm children if the embryos used in research are then placed in the uterus of a woman (57).

The ethical concerns which surround embryo research include the creation of embryos solely for research purposes, limits on the purposes of embryo research, transfer to the uterus after research, and keeping embryos alive in vitro for more than fourteen days.

Research could occur only on spare embryos created as by-products of IVF treatment of infertility. However, cryopreservation of excess embryos has limited the number of embryos donated for research. The other source of embryos for research could be creation of embryos solely for research purposes.

This would pose an important question: is creating embryos solely for research purposes a reproductive liberty? Creating embryos for research purposes is not a reproductive liberty; it is an act of liberty in the use of the human reproductive capacity (57).

One would certainly ask: is there a significant moral difference between research on embryos created solely for research purposes and research on spare, discarded embryos? Although most commissions now accept a generous degree of embryo research, ethical controversy continues to surround the production of embryos solely for research purposes. Do the ethical benefits of protecting embryos from being created solely for research purposes justify this loss? Only a few European nations and the state of Victoria, in Australia, have legislation which prohibits the production of embryos solely for research purposes (57).

Embryo research was discussed in depth at the first International Conference on Bioethics in Human Reproduction Research in the Muslim World, held in Cairo, 10th -13th December 1991 (50-58). The participants endorsed the following statements on this issue guided by previous recommendations and recent developments in this rapidly developing scientific field:

1. Cryopreserved pre-embryos may be used for research purposes with the free and informed consent of the couple.
2. Research conducted on pre-embryos should be limited to therapeutic research. The treated embryos may be transferred only into the uterus of the wife who is the owner of the ova and only during the validity of the marriage contract. This should apply to research involving microsurgical techniques such as sperm pronuclear extraction to correct polyspermy (59) and genetic diagnosis of a portion of the embryo, one blastomere or its nucleus for a specific genetic defect (60).
3. Research aimed at changing the inherited characteristics of pre-embryos, including sex selection, is forbidden.
4. The free informed consent of the couple should be obtained before pre-embryos are subjected to non-therapeutic research. These pre-embryos are not to be transferred to the uterus of the wife or that of any other woman.
5. Research of a commercial nature or not related to the health of mother or child is not allowed.
6. The research should be conducted in research institutes of sound repute such as specialised research institutes. The research should have medical justification and should be conducted by a skilled researcher.

Respect for the origin and human character of the fertilized ovum (pre-embryos) dictates the restrictions placed on the research and conducted on them. Research should be conducted with a specific reason on a very limited scale and under strict control.

Gene Therapy:

Genetic research on human embryos is part of medical research in general and the ethical requirements and rules of medical research should apply (61). These rules are governed by agreed international guidelines such as the Nuremberg and Helsinki Declarations (1963 and 1975), the CIOMS (1982) guidelines, the Inuyama Declaration (1990) and the Cairo Declaration of (1991) for the Muslim Countries (50).

There are four well known categories of human gene therapy which help to delineate the ethical gene therapy discussion (62-64), these include somatic cell gene therapy, germ line gene therapy, enhancement genetic engineering whether somatic cell enhancement or germ line enhancement, and eugenic genetic engineering.

Genetic manipulation may be desirable to remedy genetic defects. Serious ethical questions begin to arise in those borderline cases where the aim of genetic manipulation shifts from therapy to the creation of a new human type (65).

Though there is general approval of somatic cell gene therapy, ethics has not been able to solve the dilemmas of germ line gene therapy (61).

From a Muslim perspective human gene therapy should be restricted to therapeutic indications. Somatic cell gene therapy is encouraged as it should lead to remedy and alleviation of human suffering. However, enhancement genetic engineering or eugenic genetic engineering would involve changing God's creation, which may lead to an imbalance of the whole universe and must therefore be prohibited (61). Gene therapy to manipulate hereditary traits such as intelligence, stupidity, stature, beauty or ugliness may unbalance the life of man (66).

Research on Fetal Tissue Abortuses:

Is research performed on fetuses or fetal tissue obtained from abortion permissible? An example of these is research connected with the transplantation of fetal tissue into patients suffering from Parkinson's disease (67, 68). From a Muslim perspective such research is permitted provided informed consent of the couple, the owners of the fetal tissue, is first obtained (50).

Fetal ovarian tissue transfer could enable the provision of eggs for use and research in artificial reproduction. It includes the possibility of creating children who will have a fetus as their genetic mother. The genetic grandparents of these children will be the contemporaries of their birth parents. Though research on fetal ovarian tissue for the improvement of the results of artificial reproduction and other therapeutic purposes is ethically acceptable in the Muslim world, yet its use for creation of children is unacceptable as those children will not be related to their genetic parents (50).

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