Ethical considerations on in vitro fertilization technologies in Bangladesh

Corresponds to: Dr. Sharmin Islam, Asst Professor, Northern University Bangladesh, House: 54, Road: 4A, Dhanmondi, DHAKA-1209, Bangladesh. E-mail: sharmin320@hotmail.com Abstract: This paper aims to address ethical issues related to the assisted reproductive technology method ‘in vitro fertilization (IVF)’ from the Islamic Shar?‘ah. This review reflects that the Islamic ethical viewpoint IVF is rational, comprehensive, and aims at the greatest good of mankind.

Patrick Steptoe and the physiologist Robert Edwards glorified the medical world by in vitro fertilization.Robert Edwards dethroned the fact that gonadotrophic hormones could not make a mammalian ovary release eggs.He could then give barren women a carefully balanced mixture of the hormones, progesterone and estrogen which the ovaries normally release to prepared endometrium to support fertilized egg.He also demonstrated sperm capaciatation may take place outside uterine environment.Edward in one night of 1965 exposed semen on ripe egg in a Petri-dish and in the next morning he observed characteristic features of zygote under microscope.This has latter revolutionized the reproductive medicine.Steptoe's role was based on fiber optics-extremely thin tubes equipped with tiny lights and cameras that can inspect interior body cavities and acquire expertise in harvesting mature follicles(s) from the ovary.In fact, this new technology was the cutting edge factor in the development of infertility assistance 1 .
Without Steptoe's perfection of this delicate procedure, In Vitro Fertilization (IVF) would still be a dream.Lesley Brown seemed always in a gloomy mood because after nine years of trying effectively, she failed to conceive.Moreover adoption was not an easy solution at that time.Mrs. Brown's was diagnosed with damaged fallopian tubes possibly resulted from previous ectopic pregnancy.Lesley  Brown sought Steptoe's assistance who removed matured egg from her ovaries with laparoscope and exposed to her husband's semen in a petri-dish containing culture medium.Microscopic examination revealed penetration of sperm into egg and the resulting pre-embryo was cultured for two and a half days.Then, the pre-embryo was mixed with a supportive fluid and injected into Lesley's uterus [1][2][3] .Later on Lesley was declared pregnant.But, it was a normal pregnancy with some minor aliments during the whole period.On the 25 th July, 1978, a baby girl was born by caesarian section at Oldham General Hospital 1 .The baby was named Louise Brown and was the first IVF child in the world.Immediately after the birth of the baby, the father expressed his reaction in this way, "For a person who's been told he and his wife can never have children, the pregnancy was 'like a miracle'.I felt 12 feet high" 4 .

IVF: Reproductive Physiology
In vitro is a Latin phrase meaning 'in glass.'So, in embryology, it is used in contrast to in utero or 'in the uterus.'Normally, human fertilization takes place in utero, strictly speaking in the fallopian tubes as already mentioned.IVF then is fertilization that is done artificially outside the woman's body and in a test tube 5 .The popular press often refers to children conceived through the IVF techniques as 'test tube babies'.

Reasons for IVF
The primary reason for attempting IVF is to bypass damaged or blocks tubes where to produce a Bangladesh Journal of Medical Science Vol. 12 No. 02 April'13 normal pregnancy.If a woman's fallopian tubes are blocked, the egg cannot travel to the uterus.In fact, the purpose of IVF was to replace tubal function by bringing the sperm into contact with the egg in vitro and then transfer the embryo into the uterus.So, one of the most common grounds for attempting IVF is unsuccessful tubal surgery.Tubal surgery may be considered impossible in case of extensive tubal damage where the resulting tubal function would be poor.Tubal ectopic pregnancy is a serious complication of tubal surgery.For this reason, women often prefer to alternative of major surgical reconstructive procedure although they still wish to resolve their problem of tubal infertility Male infertility also may act as a factor in IVF when the number, movement or structure of the sperms is considered to be abnormal.Successful fertilization has been obtained in the case of men with concentrations of sperms as low as 5 million per milliliter of semen where the normal count range from 20 to 100 million sperm per milliliter of semen.When sperm counts are significantly reduced, however, there is often a high incidence of sperm abnormalities that may impair the effectiveness of IVF.Moreover, there is no chance of pregnancy when the sperm movements are less than 40 percent of those seen normally The third purpose is protection of progeny (hifz al nasl).Protection of progeny bears significance in medicine when medicine aims at caring children so that their good health is ensured.For successful birth of children, care for pregnant women, prenatal medicine, paediatrics.Good health is a re-requisite for healthy adulthood, procreation and continuation of human life.As Islam encourages reproduction, it advocates treatment of infertility.Protection of the mind (hifz al 'aql) in relation to medical ethics signifies the necessity of treatment of any physical or mental disease.Recovery from a disease surely brings about mental tranquility.The fifth purpose is protection of property or wealth.The wealth of any community depends on the productive activities of its healthy citizens.
Medicine contributes to wealth generation by prevention of disease, promotion of health and treatment of any disease and their sequels.Thus, Shari'ah rules and principles are meant to meet the three categories of its objectives i.e. preservation of the absolute essentials, the needs and the complementary values).The three categories consist of (a) absolute necessities (daruriyyat), (b) the complementary (hajjiyat) and (c) beautifications (tahsiniyat) Those five items belong to the necessary (dar?ri) category.If they are disrupted, the stability and equilibrium in an individual, family and social life are disrupted.Any civilization that wishes to survive must uphold and protects the above mentioned essentials.This classification is permanent and describes clearly the paramount and basic necessities of human being.These purposes need protection, preservation and promotion.So, IVF technique fully satisfies the first criteria of the purposes of Shari'ah if it is done between a legally married bond.To quote Dr. Muzammil Siddiqi, former President of the Islamic Society of North America, "based on the principle that the Shari'ah came to protect and preserve the lineage or nasab of the people and thus it is haram to marry a woman during her 'iddah or to have an intercourse with a woman who is carrying another person's pregnancy, the Muslim jurists have allowed the use of in vitro fertilization only between legally married couples during their marriage.Thus, in vitro fertilization is permissible as long as the semen and ovum are from the couple who are legally married and the fertilization takes place during their marriage, not after divorce or the death of the husband" 24 .

IVF and the Preservation of Progeny (Hifz al Nasl) (a) IVF & the Preservation of Progeny in the
. External insemination, by taking the semen of a husband and injecting it in the appropriate place in the womb or uterus of his wife, for in vivo fertilization 25 .
In order to use the husband's frozen sperm, sperms and fertilized ovum are preserved in a sperm bank in frozen state.We shall answer three questions regarding this matter.Is a man allowed to preserve his sperms in the frozen state?Are married couples allowed to preserve their fertilized ova for future use?Is it permissible to sell the sperms of the fertilized ovum?
In answering the first and second question, it can be said that there is nothing wrong with it if serious cautions are taken so that it must not mix with other sperms donated by anybody.And this sperm cannot be used except to impregnate his own wife.This can only be undertaken after free informed consent of the spouse is obtained.The excess preembryos produced can be frozen and stored in liquid nitrogen, a technique called cryopreservation.But cryopreservation should only be allowed in specially designated sperm and pre-embryo banks or ART centers accredited by the relevant health authorities.An exact and full proof system of documentation must be in place to guard against mixing of lineages and commercialism.Confidentiality of information must not be breached and tight security procedures should prevent unauthorized access to records 26-27 .In addition, the Fatwa issued by the European Council for Fatwa and Research states: "It is permissible for the wife to use the sperm of her husband for fertilization unless she is divorced or the husband dies.In case the wife is separated from her husband (i.e. by divorce or death), it's permissible for her then to get rid of the frozen sperm or its remnants" 28 .The Qur'an says: "And God has given you mates of your own kinds' and has given you, through your mates, children and children's children, and has provided for you sustenance out of the good things of life..This implies that the children's source has to be the consorts, meaning husband and wife.So, IVF is Islamically acceptable and commendable following the conditions below:

(b) IVF & the Preservation of Progeny in the
1.If it solely involves husband and wife and if it Ethical considerations on in vitro fertilization technologies in Bangladesh is performed during the span of their marriage.2. The union of sperm and ovum must not take place after the husband dies or after divorce.3. The fusion of sperm and ovum should take place only within the marriage contract.4. Any donation of alien semen is forbidden.5.A divorced woman is not permitted to receive the fertilized ovum (embryo) from her ex-husband.6.A widow is not allowed to take it after the death of her husband.7. A woman can use the frozen sperm of her husband when both of them are alive.8. Using frozen sperm before marriage is not permitted.Family bond is a very significant and strong phenomenon in Islamic bioethics.It tries to protect it in any way.Islamic ethics allows divorce but that is not very much encouraged.If the woman becomes widowed or divorced, then the marriage contract has come to an end.Stored semen of the husband would be alien to her.The woman may face a very adverse situation after the death of the husband.Moreover, when she conceives with the frozen sperm of the husband, questions may arise regarding her character.

IVF and Protection of Life (Hifz al Nafs)
In IVF procedure, some sperms, ova and zygotes may remain surplus and unused.Ethical issues related to spare embryos involve the following questions: 1.The most important ethical issue in this process seems the question: should an embryo which is formed after fertilization in a test tube and is not yet in the womb of the mother be considered a human being with all the rights of a human being? 2. Is it correct to produce embryos only for research purpose?3. Is it right to destroy the spare embryos? 4. Can these embryos be used for research purpose?etc. Regarding the first question, we should have a clear understanding of the concept of soul or 'ruh' based on the Qur'an.Allah, the Almighty speaks about this idea in different verses and several meanings were given by commentators.However, Yousuf Ali and Mohammad Asad considered 'ruh' 'divine inspiration'.According to the Qur'an, the stage at which the soul breathed into the forming body within the womb, takes place after it has passed through the stages of Nutfah, 'Alakah, Mudgah, bone formation and flesh formation that covers the bone 31 .
The Qur'an says: "Now, Indeed, We create man out of the essence of clay, and then We cause him to remain as a drop of sperm in [the wombs] firm keeping."32 .
These verses indicate seven stages of fetal development 31 .

The First stage: This point to the creation of
Adam from clay---that is soil and water.To put it in another way: sperm and ovum come from human bodies which are built from nutrients that originate from clay.The Qur'an says, "who makes most excellent everything that He creates.Thus, He begins the creation of man out of clay; then He causes him to be begotten out of the essence of a humble fluid." 33 .
2. The Second stage: The outcome of spermovum unification is the formation of 'zygote'.This is explained scientifically by saying that half chromosomes are derived from each parent and then added together to form the fertilized ovum.3. The Third stage: This is the stage of the hanging clot which forms around the 7 th day from fertilization.The picture of this early fetus looks like an object hanging to the endometrium by fine villi which will develop further in stages.Many scholars identify this stage as the first and very early form of life in human development.4. The Fourth stage: The fetus in this stage of development looks like a partially chewed piece of meat( The Arabic word 'mudgahah' is used to refer to this flesh mass or mass of somites).This stage begins at the end of the 3 rd week or the beginning of the 4 th week. 5.The Fifth stage: This is the stage of bone development.Embryo is nothing but a boneless lump.Its cartilage tissue is transformed into bones in due time as described in the Qur'an which is followed by their being clothed by muscular flesh (The Arabic word 'lahm' stands for the muscular flesh).The Qur'an says, "and then We create out of the drop of sperm a germ-cell, and then We create out of the germ-cell an embryonic lump, and then We create within the embryonic lump bones, and then We clothe the bones with flesh -and then We bring [all] this into being as a new creation: hallowed, therefore, is God, the best of artisans!"34 .
6.The Sixth stage: Several days after bone development, early muscles start around the vertebrae at the 6 th week and muscles around the extremities at the 7 th week.7. The Seventh stage: This is the stage in which a new creation is formed.According to some contemporary scholars, fetuses vary slightly in acquiring 'ruh'.The least time is 40 days and the maximum is 45 days.Some still hold the view that 'ruh' starts after 120 days of fertilization 35 .
So, our decision is easy to derive from the above explained process of human development on the basis of the Qur'an that there is nothing wrong with the idea that embryos created in the test tube but not implanted in the womb has no soul or life.Thus, it is a lifeless creature.If it is not placed in the womb it will not survive.Even a fertilized ovum outside the womb or inside it without implantation cannot end up as a human being 31 .
To address the second question, we can say that it is true that compared to stem cells derived from early embryos, the potential of tissues from the umbilicus, fetuses (mature embryos) and adult tissues are more limited.Nevertheless, embryos must not be created for the purpose of research motive only since to create a life in order to end it rivals the actions that belong only to God.Experimentation in human pre-embryos would be allowed only if it is for the good of the individual pre-embryos or if the mother's life is in danger following the research the pre-embryos can be transferred only to the owner of the ova, and only during validity of a marriage contract 36  To address the fourth question, we can say that the surplus fertilized embryos might have a good potential for research purpose for human benefit.But the cryopreserved pre-embryos may be used for research purposes with the free informed consent of the couple and should be limited to therapeutic research.The treated pre-embryos may be transferred only to the uterus of the wife, who is the owner of the ova and only during the marriage span.Research aimed at changing the inherited characteristics of pre-embryos including sex selection is not allowed.Non-therapeutic research is permissible on excess pre-embryos to improve the treatment of infertility, contraception, reproductive medicine, genetics, cancer, and embryology.But free informed consent of the couple is required 37 .
Among the fundamental principles of Ijtih?d is maslahah mursalah (consideration of public interest).In dealing with the issue of spare embryo research, it is important to keep all of these principles and the basic legal framework in mind.
When a Muslim scholar reaches a conclusion about stem cell research, he should evaluate such conclusion in light of public interest.If the well-being of the community is being threatened for some reason, then the scholars must consider that fact, which is subsumed under principle (3) above, in reaching their final decisions.This is one reason why laws change with the change of time and place.Thousands of embryos that would otherwise be discarded in fertility clinics could potentially be used for research.This is not contradictory to the spirit of Islamic principles.Even it is a societal obligation to perform research on these extra embryos instead of discarding them because people would surely be benefited from such research.But there should be strict guidelines and proper procedures to ensure there is no potential abuse.

IVF and Protection of the Mind (Hifz al 'Aql)
IVF must fulfill the requirement of mental satisfaction.It is true that although this technique seems very simple, in fact it is not so.The couple has to come under medical treatment and different kinds of procedures month after month and even year after year.The woman has to have fertility drug for stimulation of the ovum.But still, some couples prefer trial and error method rather than becoming childless.So, if it leads to their mental satisfaction, then, why should they not try for it?If any couple becomes tired and exhausted due to failure of several attempts, then what would be their consolation?They can remember the verse of the Qur'an, "God's alone is the dominion over the heavens and the earth.He creates whatever He wills: He bestows the gift of female offspring on whomever He wills, and the gift of male offspring on whomever He wills; or He gives both male and female [to whomever He wills], and causes to be barren whomever He wills: for, verily, He is allknowing, infinite in His power" 38 .

IVF and Protection of Wealth (Hifz al Mal)
Islamic legal principles not only try to ensure peoples' faith, progeny, life, and mind but also are apt to preserve the wealth of mankind so that they would not become helpless in adverse situations.IVF is really an expensive procedure.If a couple is in such a situation that attempt of IVF will make them insolvent in future, and then they should refrain from.An Islamic society should give priority to physical health and poverty than IVF.

IVF and protection of Faith (Hifz al Din )
IVF if performed within marriage bond and marriage span does not have any conflict with the protection of faith (Hifz al Din).Rather this technique, if it is successful in removing the barrenness of a couple may help them undertaking all the responsibilities of ibadat.

Conclusions
The above study reveals the fact that while Western secular bioethics is arguing to validate the use of donor sperm and egg in IVF technique, Islamic bioethics thinks about the problem of lineage.The approach of Islamic bioethics seems deeper and thought-provoking for the welfare of the society as a whole because it strictly keeps the identity of the child and inheritance law intact.A very coherent and logical form of social justice is reflected here.Islamic bioethical ideas about IVF is dynamic and proves that long term good is beneficial than temporary satisfaction of desires.

Light of the Necessity of Procreation Islamic
mine is an old man?Verily, that would be a strange thing indeed!"Answered [the messengers]: "Dost thou deem it strange that God should decree what He wills?'O' The grace of God and His blessings be upon you, O people of this house!
20oethics has a positive attitude towards IVF if it is carried out by a legally married couple.For married couples, procreation is not only encouraged but also a necessity, daruriyyat.As IVF aims at procreation, this technique is most welcome in Islamic Bioethics.Two stories of infertility in the Qur'an truly reflect the necessity of progeny.One is the story of Ibrahim (AS) and his wife Sara another is that of Zakariya (AS).Regarding the first couple's desire for children it is mentioned in the Qur'an: "And his wife, standing [nearby], laughed [with happiness]'"; whereupon We gave her the glad tiding of [the birth of] Isaac and, after Isaac, of [his son] Jacob."Saidshe:"Oh,woe is me!' Shall I bear a child, now that I am an old woman and this husband ofThe craving for children of Zakariya's heart is expressed in the Qur'an in the following ways: "In that self-same place, Zachariah prayed unto his Sustainer, saying: "O my Sustainer!Bestow upon me [too], out of Thy grace, the gift of goodly offspring; for Thou, indeed, hearest all prayer."Thereupon,as he stood praying in the sanctuary, the angels called out unto him: "God sends thee the glad tiding of [the birth of] John, who shall confirm the truth of a word from God, and [shall be] outstanding among men, and utterly chaste, and a prophet from among the righteous."[Zachariah]exclaimed:"O my Sustainer!How can I have a son when old age has already overtaken me, and my wife is barren?"Answered[theangel]: "Thus it is: God does what He wills"20.gift of John, having made his wife fit to bear him a child: and, verily, these [three] would vie with one another in doing good works, and would call unto Us in yearning and awe; and they were