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In the Name of Allah the

Most Gracious

The Most Merciful

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Ethical aspects of ART in the Arabic-speaking world

Professor Hesham Al-Inany, M.D, Ph.D.Professor of Obstetrics & GynecologyFaculty of Medicine , Cairo University

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Please note: • The population diversity of more than

300 millions from 22 Arab countries is not easy to demonstrate.

• At certain points one or more countries are selected as representatives or used as examples.

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Introduction• The ability to reproduce is a basic

element of reproductive health. • Infertility, in itself, may not threaten

physical health, but it can certainly have a serious impact on mental and social health.

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ART

• IUI, IVF, ICSI, and recently PGS, PGD have offered solutions to subfertile couple to achieve their parenthood dreams.

• More than 3 million babies have been delivered by ART till now allover the world

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Arab World• The ethical aspects of ART are very

important in determining the degree of acceptability of such programs in Arab world

• the conservative culture of Arab world is governed by strong religious sentiments

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Arab World

• More than 90% of arab are muslims• The basic concept of Islam is to

avoid mixing genes, • As Islam enjoys the purity of genes

and heredity, It deems that each child should relate to a known father and mother.

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Not only patients

• The physician is also concerned about the legal basis of acts undertaken on the basis of ethical precepts

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LAW• In all arab countries, there is no official

legislation to control assisted reproduction, with the exception of Tunisia

• Although most Western countries have adopted legislation to govern ARTs, Canada to date has not.

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Is it loose!!!

• however, ART in arab world is strictly regulated by two factors:-

Religious lawsguidelines

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Religious

• Since marriage is a contract between the wife and husband during the span of their marriage, no third party can intrude into the marital functions of sex and procreation.

• A third party is not acceptable whether he or she is providing a sperm, an egg, an embryo or a uterus (Serour and Omran, 1992).

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Fatwa

• So long as these procedures are carried out by expert scientists

• and are clearly indicated for the couple, and so long as the sperm cell is from the husband and the egg is from the wife with no mixing with other cells from other couples or other species,

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Fatwa (cont.)

• and that the conceptus is implanted in the uterus of the same wife from whom the ova were taken, then IVF is an acceptable line of treatment (al-Azhar Fatwa, 1980).

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Christian point of view• About seven million Egyptians are

Christians (Copts). Christian minorities are also present in almost all Arab countries. They follow the Alexandria Orthodox Church, the Catholic Church and a smaller number follow the Protestant church.

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• The pope of Alexandria, who is the spiritual leader of the Orthodox Church, clearly stated that Christian beliefs are identical to Muslim beliefs concerning assisted reproduction. (Aboulghar et al, 2007)

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• These religious regulations for both Muslims and Christians are followed strictly by all IVF centres in the Arab world with the exception of Lebanon.

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Guidelines

• The Ministry of Health, the doctors’ syndicate, the Egyptian Fertility Society and the Middle East Fertility Society all issued guidelines which conform with the religious regulations.

• In addition there are detailed specifications for an IVF centre and description of inspection and quality control procedures

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However

• IVF centres in general do not conform to recommendations concerning the number of embryos transferred

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Guidelines

• A November 2000 workshop organized by the International Islamic Center for Population Studies and Research, Al-Azhar University, Cairo, considered use of assisted reproduction technologies (ART) in the Islamic world.

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Tunisian law• Tunisia is the only Arabic-speaking

country which has a law to regulate IVF. • The law states that ARTshould be

performed with gametes of a married couple, and frozen gametes or embryos are only to be used if the couple is alive and the marriage contract is valid and with valid consent.

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• The law provides specifications for IVF centres and regulations to maintain standards and it ensures regular inspections and confidentiality for all patients.

• All centres should keep a complete and detailed register of all procedures. There are different levels of penalties for centres violating the law.

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Lebanon: an exception

• The presence of so many ethnic groups in Lebanon and several religions allow more freedom in family and heredity laws. Each sect can use the regulations of his or her ethnic or religious background.

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For example• According to the Druze religion (a

minority group), donation of oocytes between sisters may be permitted.

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Specific conditions

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Cryopreservation• According to Islamic Sharia or law

there has been no definite clear opinion regarding cryopreservation. In Egypt cryopreservation is done under strict conditions after couples have signed a consent for the wife who is still legally married to the same husband

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• Transfer of frozen-thawed embryos, or using frozen-thawed sperm after termination of the marriage contract by divorce or death of the husband is also forbidden.

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In Tunisia

• Cryopreservation is allowed for five years, but it can be extended with a written consent signed by the couple for another period of five years.

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PGD

• It is accepted to use preimplantation genetic diagnosis to prevent hereditary diseases

• sex selection has been permitted for family balancing.

• Certain precautions and restriction were suggested to be applied to avoid its abuse

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Cloning

• human reproductive cloning is condemned, but cloning human embryos for stem cell research is considered acceptable Serour & Dickens , 2001

• The majority of Muslim jurists distinguish between reproductive and therapeutic cloning (Larijani , Zahedi F.,2004)

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Surrogate Mother

• surrogate motherhood is not allowed because of the legal position of the mother in Islamic shari'a and consequent inheritance rights on the one hand and sociological significance of motherhood on the other. (Arbach , 2002)

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Multifetal pregnancy reduction

• According to Islamic view, MFPR 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.

• Every attempt should be made to prevent the incidence of multiple pregnancy, especially high-order multiple pregnancy.

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• When MFPR is performed, it is not performed with the objective of inducing abortion. MFPR is performed with the objective of increasing the chances of continuation of the pregnancy and the chances of survival of the remaining fetus or fetuses (al-Shazil, 1995).

Pregnancy in the postmenopause

ART allow postmenopausal women to become pregnant. The physiological process occuring with pregnancy no doubt task and exhaust the health reserves of the woman.

Pregnancy in the postmenopause, involves egg donation, accordingly, using donated eggs is ethically unacceptable in the Muslim World

Pregnancy in the postmenopausal using couple’s frozen embryos is associated with increased maternal risks and need further evaluation.

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Embryo research

• According to religious recommendations, research would occur only on spare embryos created as by-products of IVF treatment for infertility.

• However, the wide use of cryopreservation of extra embryos has limited the number of embryos donated for research

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• Cryopreserved pre-embryos may be used for research purposes with the free and informed consent of the couple.

• These pre-embryos are not to be transferred to the uterus of the wife or that of any other woman

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Summary

In the Arabic-speaking countries, assisted reproduction treatment is strictly controlled by religious rules that basically do not allow involvement of a third party in the procedure.

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• Egg donation, sperm donation and surrogacy are not allowed.

• Assisted reproduction treatment should only be performed in the presence of a valid marriage contract

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not to mingle genealogical lines

The concept