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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0011-REPRODUCTIVE TECHNOLOGY

Lecture for 4th year medical students on 11th and 18th November 2000 by Professor Omar Hasan Kasule, Sr.

OUTLINE

1.0 ASSISTED REPRODUCTION

A. Infertility

B. In vivo insemination

C. In vitro fertilization

D. Other Alternatives

E. Issues of Paternity and Maternity

 

2.0 CONTRACEPTION

A.  Fertility

B.  Population and birth control

C.  Male contraception

D. Female contraception

E.  Socio-demographic impact

 

3.0 SEX SELECTION and SEX CHANGE, al tahakkum fi al jins

A. Background to Gender Preference

B. Non-invasive methods

C. Sperm separation

D. Intra-uterine

E.  Post-natal sex change

 

4.0 CLONING

A. Background to cloning

B. Medical Benefits

C. Medical Dangers

D. Legal Implications

E. Socio-demographic Implications

 

1.0 ASSISTED REPRODUCTION

A. INFERTILITY

DEFINITION

Infertility is defined as failure to get pregnant after 1 year of regular intercourse. Involuntary infertility can be primary or secondary. Subferility is both partners may manifest as infertility. Both male and female infertility exist. In situations of sub-fertility in both, complete infertility may ensue. Infertility is considered a serious condition because it could lead to psychological distress, marital problems, and even marital failure. At the ummatic level widespread infertility could spell demographic weakness, a security threat.

 

HISTORY

Infertility was mentioned in the Qur’an as ‘uqm (p. 821 3:40, 19:5, 19:8, 42:50). Desire of parents for children is natural. The prophets Ibrahim and Zakariyyah made dua to Allah to give them offspring. Prophet encouraged marrying young fertile women for glory of the ummah ‘Alaykum bi al abkaar (KS 546). Marrying women was considered a source of good, khayr, inna khayra hadhihi al ummat akthahruhum nisa an (KS 546).

 

CAUSES

Natural causes of infertility: Natural causes of infertility may be male or female factors. The male factors are: sperm anomalies, reduced sperm mobility, reduced sperm numbers, and impotence. Female factors are: anovulatory dysfunction, hormonal imbalance, tubo-peritoneal disease, and cervical disease. Some factors operate in both males and females such as congenital malformations, infections, neoplasms, immunological anomalies, and advanced age.

 

Causes of infertility related to life-style: sexually transmitted disease, long-term use of contraceptives, age, infrequent coitus, unnatural coitus.

 

Infertility due to medical or surgical complications: irradiation, surgery, sterilization.

 

DIAGNOSIS

Female infertility: documentation of ovulation, evaluation of ovulation (basal body temperature, serum progesterone, endometrial biopsy), tubal-uterine evaluation likehysterosalpingo-oophorectomy, laparascopy, Post-coital tests

 

Male infertility:  Semen analysis, sperm antibodies

 

TRADITIONAL METHODS OF TREATMENT: MALE INFERTILITY

Medical Methods: treat infection, treat impotence.

Surgical Methods: Repair varicocele. Vaso-epidydimostomy. Vasostomy. Repair ejaculatory duct obstruction. Treat ejaculatory disorders: eg retrograde ejaculation

Treat side effects: psychological, medical, legal, ethical

 

TRADITIONAL METHODS OF TREATMENT: FEMALE INFERTILITY

Medical methods: treat infections, hormonal imbalances, and stimulation of ovulation. Immune suppression for sperm antibody

Surgical methods:  can be used for congenital malformations, neoplasms, and blocked fallopian tubes.

Treat side effects: psychological, medical, legal, ethical

 

LEGAL BASIS FOR SEEKING TREATMENT OF INFERTILITY: MAQASIDI ANALYSIS

Procreation for a married Muslim couple is considered among the necessities, dharuraat. It fulfils the purpose of the law about hifdh al nasl. Parental rights are asserted under the purpose of the Law about protecting the lineage, hifdh al nasab. a child is produced only through marriage, majiu al walad bi al zawaaj p 1323 3:47, 4:1, 16:72, 19:20. LINEAGE, nasab: It is prohibited to claim a false lineage (KS 543)

 

 

 

B. IN VIVO INSEMINATION

Artificial intra-uterine insemination with husband’s sperm, talqiih sina’i dhaati is permitted by the Law provided safeguards are taken to ensure that spermatozoa do not get mixed up in the laboratory or the clinic. There is a consensus among jurists on prohibition of artificial in vivo insemination of a wife with donated sperm from a strange man, talqiih sinna’i ajnabi,. There is a consensus among jurists on prohibition of artificial in vivo insemination of a strange woman with the husband’s sperm

 

C. IN VITRO FERTILIZATION

The Law permits invitro fertilization if the sperm and ovum are from legally wedded husband and wife and the zygote is implanted in the same wife. No paternity or maternity issues arise here.

 

According to some jurists, the Law permits invitro fertilization if the sperm is from a husband and the ovum is from a legally wedded wife, and the zygote is implanted in a second wife of the husband. No paternity issues arise here. There is controversy about maternity. Some scholars consider the woman who gave the ovum as the mother and the women who carried the fetus in her uterus as a foster mother. Some jurists consider the mother who delivered the baby the legal mother.

 

There is consensus among jurists that invitro fertilization is prohibited if the sperm is from the husband and the ovum is from the wife and the zygote is implanted in a surrogate mother.

 

There is consensus among jurists that a married woman cannot have a zygote implanted into her uterus if a sperm from a donor who is not her husband fertilized it.

 

There is consensus among jurists that the Law prohibits implantation of a fertilized zygote in a wife if another woman donated the ovum and the sperm is from her husband or a strange man.

 

D. OTHER ALTERNATIVES

FUTURE TECHNOLOGIES

Animal uterus

Artificial uterus

Male pregnancy

Embryo transfer

 

ALTERNATIVES TO TECHNOLOGY

Foster care

Foster care of husband’s children from co-wife or from previous marriage

Foster care for abandoned outside children

 

Polygamy

Polygamy can be an alternative to IVF for the man but not the women

Open adoption

The infertile couple can adopt a child provided information about its biological parents is not hidden

 

Patience and ibadat

The infertile couple can accept their fate and be patient

 

E. ETHICAL AND LEGAL ISSUE

Some Muslims will, despite the prohibition, still undertake the prohibited insemination or invitro fertilization either due to ignorance or disobedience. Children will be born and legal issues will arise that cannot be brushed aside.

 

The issue of paternity and maternity is settled on the basis of biological inheritance. The position of the Law is that the source of the ovum is the biological as well as the legal mother; the surrogate mother has rights as a foster mother and these are well explained in the Law. In the same way the source of the sperm is the biological and also legal father. The owner of the ovum is the biological as well as the legal mother. Some scholars had opined that the surrogate mother is the legal husband of the surrogate mother is legal father on the basis of the hadith of the prophet, al walad li al firaash wa li al ‘aahir al hajar. This hadith was in the special context of adultery by a married woman who gives birth to a child. Since it was impossible at that time to be certain who the biological father was (it could be the legal husband or the adulterer), the prophet ordained that the child should belong to the legal husband. This is understandable for the protection of the interests and welfare of the child. It is also in conformity with the principle of the Law, qa’idat al sharia, that certainty cannot be voided by doubt. In this case the legal husband is the certainty and the possibility of the adulterer being the biological father is the doubt that could not be proved at that time to become a certainty. Even with this ruling the legal husband still has a recourse to li’aan by which he can legally deny paternity if he has sufficient personal presumption, not subject to legal proof, that the child is not his. Modern DNA technology removes any doubts about paternity and maternity. It should be mandatory that in all cases of in vivo insemination, whether legal or not, DNA analysis should be carried out to confirm maternity or paternity. Even in legal cases of insemination or fertilization, mistakes could occur in the laboratory or clinic leading to mix-up of ova and sperms.

 

As regards unused fertilized ova, zygotes, there are four alternatives. There is consensus among jurists that they can legally implanted at a later stage in the wife who was the source of the ovum so that she can have a second pregnancy; this implantation must be carried out during the life of the husband to prevent him from having children after his death. There is consensus among jurists that donating them to a childless couple so that they can be implanted in the wife, as a surrogate mother, is prohibited by consensus of jurists. There is no consensus yet among jurists on the remaining 2 alternatives: destroying them or using them for scientific research.

 

2.0 CONTRACEPTION

A.  FERTILITY

PURPOSES OF HUMAN REPRODUCTION

The purposes of the human reproductive function can be considered at the individual, family, community, and human levels. Reproduction at an individual level fulfils a deeply felt human desire for self-perpetuation in order to achieve a form of immortality. Parents are proud of their children, al tafakhur bi al awlaad (p 1322 9:55, 9:85) and naturally desire to have many, al takathur bi al awlaad (p 1322 9:69, 18:39, 19:77, 34:35, 57:20). Children help cement and strengthen the marital bond. As regards the community level, the prophet encouraged Muslims to have as many offspring as possible to give glory to the ummat so that it may be the largest of communities. When righteous people have many children and bring them up to be righteous they will be spreading light and truth in the next generation in a very effective demographic strategy. At the level of the human species, reproduction is necessary to ensure survival of the human race. Contraception in all its forms runs contrary to the objective of human reproduction mentioned above especially the human survival instinct. Contraception is against basic human nature. There must exist very strong reasons and motivators to make humans limit their reproductive capacity.

 

LOW HUMAN FERTILITY

Human fertility is very low. Conception can occur only in a narrow window of 3-4 days in the menstrual cycle when the ovum is released. Both the ovum and the sperm have a limited life span. Human conception is of low efficiency. Many ova and sperms are shed but are not utilized. It is possible for one man to be the father of all humans on earth because he produces enough sperms over his lifetime. Humans, unlike some animals, do not time their copulation to coincide with the release of the ova. Despite the low fertility humans down the centuries have for various reasons wanted to control conception and birth.

 

HEREDITY

Offspring resembles both parents because they both contribute to the genetic material (KS 574). Quantitatively both parents have equal contributions of genetic material to the offspring. The final appearance of the offspring is not an ‘average’ of the two parents because recessive genes from one parent are overshadowed by dominant ones from the other parent in determining particular traits.

 

MAQASIDI ANALYSIS

Marrying and getting offspring is obligatory, wajib, for the community otherwise it will weaken and disappear. This fulfils the purpose of the Law, maqsad al shari’at, to protect and preserve progeny, hifdh al nasl. Any policy or practice at the community or national level to control births is repugnant to the Law. It is highly recommended that each individual couple play their role in fulfilling the purpose of the Law by having children. Thus procreation for the individual is under the legal rubric of permissibility, ibaahat, and not obligation, dharuurat. In any special situation of low Muslim population and there is an economic or military need for more births, then procreation becomes a personal obligation, fardh ‘ain, on every couple. There is a basic permissibility of contraception as is clear from the hadith of the prophet on coitus interruptus, tarkhis fi al ‘azal (KS 154). It is however considered offensive, karahiyat al ‘azal (KS 155) and is prohibited without the wife’s permission, karahiyat al ‘azal ma’a al hurrat (KS 155).

 

Since child-bearing is one of the purposes of marriage, any decisions on contraception require mutual agreement between the two spouses otherwise one can claim denial of parenthood rights in marriage. In cases in which contraception is a necessity, dharuurat, for preserving the life of the mother, the agreement of the husband is not required but he has the option of recourse to divorce. Choice of the method of contraception must be based on the purposes and principles of the Law. It should not encourage immorality or in any way be conducive to spread of evil, fasaad, in violation of the purpose of preserving religion, hifdh al ddiin. It should not be harmful to the life and health of any of the parents under the purpose of preserving life, hifdh al nafs. It should also not destroy life of the zygote or fetus because it is life preserved under the purpose of hifdh al nafs. It should not be a cause of stress that can lead to severe psychological disturbance in violation of the purpose of preservation of intellect, hifdh al ‘aql. It should not permanent and irreversible because it would violate the principle of preservation of progeny, hifdh al nasl. Jurists have discussed sterilization of both males and females and have not reached a consensus. Each of the following indications of sterilization has been discussed but with no unanimity: prevention of hereditary diseases, high maternal obstetric risk at a subsequent pregnancy, medical conditions aggravated by pregnancy, mental instability, and purely economic considerations.

 

B.  POPULATION AND BIRTH CONTROL

MOTIVATION

We have to distinguish population control as a national policy from family planning as a choice that individuals and families make. The motivations for population control at the community or national level are based on greed not to share wealth. Malthusian theories and Darwinism provide a philosophical framework for this type of thinking. The motivation at the individual or family level varies by the level of economic development. In rich industrialised countries, birth control is done not for fear of poverty because individuals and the society have resources to look after more children; the main reason is desire for freedom either to enjoy life fully without being disturbed by looking after children or the freedom to indulge in sexual intercourse without consequences. In poor countries the elite have the same motivation for birth control as the industrialised countries. The poor and the disadvantaged fear inability to look after additional children, and fear for the health of the mother and the offspring. There are valid reasons for family planning for an individual family that the Law recognizes provided the couple involved are making a voluntary decision and free choice. There is no basis in Law for instituting population control as a community or national policy. Allah provides for all creatures and the argument that the resources of the earth are limited is not acceptable. The problem in the world today is not limited resources but inequitable distribution of resources. The rich use a disproportionate share of the resources and in the greed of not wanting to share with the poor; they become strong proponents of population control in poor communities. They also fear that the poor may use their numbers to try to break up the unjust system of resource distribution.  Thus population control policies have many aspects that have to be considered carefully:  military and security, political, economic, moral, and cultural.

 

HISTORY

Contraception: Contraception was practised by all societies past and present. Ancient Egypt, ancient Greece, and the Roman Empire all had contraceptive methods though in many cases of doubtful effectiveness. Arabs in the pre-Islamic period used coitus interruptus, ‘azl. The sex revolution of the 1960s was made possible by the development of the contraceptive pill. For the first time in human history an effective birth control method became widely available and encouraged much promiscuity in all countries of the world. With availability of effective contraceptives population control policies have become more effective. Many countries have instituted punitive measures for couples that have more than the set number of children. Many incentives were offered for smaller families. The effects are already obvious. Some countries in Europe are already experiencing a demographic problem of too few young people and too many old people and are having second thoughts about population control.

 

Abortion: Abortion was used in the past and continues to be used by those who do not want to bear children and find themselves pregnant. It is a crime under the Law because it involves destruction of life.

 

Infanticide, wa'ad: The pre-Islamic custom of killing girls, qatl al banaat fi al jaahiliyyat was condemned by the Qur'an (p. 914 6:137, 6:140, 6:151, 17:31, 60:13). Killing of children for fear of poverty, qatl al awlaad khashiyat ‘imlaaq (p. 498 6:151, p 498 17:31). The Qur’an refuted the economic reason for wanting smaller families by informing us that each animal, daabat, has its provisions from Allah (p. 498 11:6) and that the animal does not carry its provisions with ir (P. 499 29:60). Those innocent children will enter jannat (5:58, KS 575). Pharaonic Egypt instituted a population control policy when the number of Banu Israil increased. Selective infanticide of boys was carried out, qatl al awlaad 'inda al fara'inat (p 914 2:49, 7:127, 7:141, 14:6, 28:4, 28:9, 40:23-25).

 

Genocide: Ethnic cleansing and other forms of genocide have been a characteristic of the 20th century and are likely to continue into the next century.

 

C.  MALE CONTRACEPTION

MALE REVERSIBLE METHODS: The reversible methods for males are the condom, coitus saxanicus, coitus reservatus, and coitus interruptus. Coitus interruptus is allowed, tarkhiss al 'azal (KS 154 KS 154-155: Bukhari K67 B96; Bukhari K82 B4; Bukhari K77 B18; Muslim K77 H15-H28; Abu Daud K12 B46; Tirmidhi K9 B39; Nisai K26 B55; Ibn Majah K9 B30; Darimi K71 B36; Muwatta K29 H95-H97, H99, H100; Ahmad 3:22, 26, 33, 47, 49, 51, 53, 57, 59, 63, 68, 71, 72, 82, 88, 92, 93, 140, 309, 312, 313, 377, 380, 386, 388, 450; Ahmad 6:361; Tayalisi H 1244, 1697, 2175, 2177, 2193, 2207). Although permitted, coitus interruptus is considered offensive, karahiyat al 'azal (KS 155: Muslim K1 H31; Tirmidhi  K9 B40; Ibn Majah K9 B61; Muwatta K29 H98;  Ahmad 1:380, 397, 439; Ahmad 6:361, 434; Tayalisi H 396. It is forbidden if the wife does not give permission, al nahyu 'an al 'azal illa bi idhniha (KS 155: Ahmad 31). 

MALE IRREVERSIBLE METHODS: Vasectomy is the only available irreversible contraceptive method for males. It has minimal medical side effects that must be considered. The psychological side effects are more severe: regret over missed births, inability to have children after sterilization, need for more children after divorce & remarriage or when all children die.

 

D. FEMALE CONTRACEPTION

FEMALE REVERSIBLE METHODS: Reversible methods for females are either mechanical or chemical. The mechanical barriers are: the diaphragm, the cervical cap, the vaginal sponge, and the IUD. Often neglected and not mentioned are the traditional non-invasive methods of sexual abstinence and using the natural rhythm of menstruation to avoid coitus during the fertile days of the menstrual cycle. Each of these methods has advantages and side effects that are either physical or psychosocial. Spermicides kill sperms. The Intra-uterine device prevents implantation of a fertilized ovum and is considered an early form of abortion since life starts at conception. The safest and perhaps the least effective is the rhythm method; pregnancy will still result even if it is used carefully. It however has no associated legal or ethical problems. The oral contraceptive pill suppresses ovulation. The OC has revolutionised contraceptive practice since its development in the 1960s. It is largely responsible for the excesses of the sex revolution in which people saved from fear of pregnancy engaged in sex on an unprecedented scale. The sequential progesterone-estrogen pill's mechanism of action involves: inhibition of ovulation by suppressing FSH and LH, alteration of cervical mucosa and inhibiting sperm transport, interference with ovum transport, and inhibition of implantation by suppressing normal endometrial development. Besides its contraceptive actions, the pill is useful in menstrual regulation. Among its adverse effects are: circulatory disorders such as MI, venous thrombosis, CVA, and HT; abnormal uterine bleeding, carbohydrate intolerance, neoplasia, and gall bladder disease.

 

FEMALE IRREVERSIBLE METHODS: There are two main irreversible methods for females: tubal ligation and hysterectomy. Tubal ligation is a simple surgical procedure that is reversible with much difficulty. Hysterectomy is not done deliberately for purposes of contraception. It is carried out for some other purpose and it serves the additional purpose of contraception.

 

E.  SOCIO-DEMOGRAPHIC IMPACT

SEXUAL PROMISCUITY

Availability of safe contraception removes the fear of pregnancy and encourages more people to engage in illegal extra-marital sexual activity such as teenage sex, pre-marital sex, and adultery. The spread of zina is a direct cause of family breakdown.

 

TEMPORARY MARRIAGES

Availability of safe contraceptives will encourage temporary unstable unions because people are not worried about child responsibilities. Thus couples will marry with secret intention to divorce, zawaaj bi niyyat al talaaq

 

POPULATION IMBALANCES

Population equilibrium cannot be predicted by mathematical equations and cannot be controlled by policies and regulations. Attempts at population engineering lead to imbalances. Population imbalances result from widespread birth control at the community or national levels. The impact of birth control policies may be more in population sub-groups leading to political tensions. Decrease of population may lead to military and economic weakness.

 

PRELUDE TO GENOCIDE

Widespread practice of birth control makes it easier to accept and practice genocide.

 

3.0 SEX SELECTION and SEX CHANGE, al tahakkum fi al jins

A. BACKGROUND TO GENDER PREFERENCE

Sex preference is natural. Most human societies prefer male children. The prophet Zakariyyah asked Allah for a male offspring. Omran also had wanted a male offspring but got a female instead, Maryam. Gender selection is by Allah (shura: 49) and no human efforts will contradict Allah’s will. Human efforts can only succeed if Allah wills so. Efforts to get an offspring of a particular gender are in general permissible because the dua that prophets made are considered part of the effort. Discussion centers around the methods used because some are permitted while others are prohibited.

 

B. NATURAL METHODS: not effective?

Selecting days of copulation before and after ovulation

Changing upper vaginal chemistry artificially

 

C. ARTIFICIAL METHODS

Separation of male and female sperms by centrifuging and invitro insemination

 

Invitro fertilization: gender pre-selection and implanting only zygotes of desired gender?

Sex change by genetic engineering has been carried out in animals. ?Technically possible in humans but not yet attempted.

 

Exposure of the fetus to specific hormones may affect embryological development of the sex organs

 

Amniocentesis and chromosomal analysis may be followed by abortion. The position of the Law is that what leads to haram is also haram. Amniocentesis cannot therefore be offered unless there is a definite medical indication.

 

D.  POST-NATAL SEX CHANGE

Sex change operations for hermaphrodites

 

E. LEGAL RULINGS

Some jurists consider sex selection permissible for the couple but are prohibited when they are part of community or national policy. There are long-term consequences that must be considered. Severe gender imbalance will threaten marriage and lead to family breakdown. Eventually the purpose of the law to preserve progeny, hifdh al nasl, cannot be fulfilled.

 

9.1.4 CLONING

A. BACKGROUND TO CLONING

NATURE OF CLONING

Cloning was achieved in sheep by transfer of a nucleus from the somatic cell of an adult animal into an egg whose nucleus had been removed. A live sheep was subsequently born (1, 2, 4). This process seems to be technically feasible in humans but has not yet been attempted.

 

Cloning is not creation of new life from basic organic and non-organic matter. Creation of life de novo is the prerogative of God alone. Cloning starts with a living nucleus with its genetic characteristics (3). The DNA in the nucleus programs the product resulting from cloning. A tissue or a whole organism may be cloned.

 

Cloning as a concept goes far beyond the natural method of human sexual reproduction. If human cloning is ever achieved in practice, it will not be the first exception to human sexual reproduction. The Prophet Adam had neither a father nor a mother. The Prophet Isa had a mother but no father. Asexual reproduction is common in the animal and plant kingdoms. Bacteria, viruses, and other microorganisms reproduce asexually.

 

Cloning is a form of reproduction without male-female interaction. The clone is the exact replica of original. Genetic recombinations that are responsible for the great variety of normal reproduction do not occur in cloning.

 

MOTIVATION

Cloning relates to a powerful human emotion of self-perpetuation. The desire to perpetuate their kind or continue living in some way is a very strong drive in humans. It is satisfied partly by the sexual reproductive process in which the person's identity continues in their offspring. The emotion is also obvious in animist beliefs in ghosts and ancestral spirits. Reincarnation is another interpretation of self-perpetuation. The ancient Egyptians preserved their dead as mummies in the hope they will live again. Many political leaders have tried to leave behind monuments so that the future generations may know about their achievements.

 

SPECULATION

The Islamic tradition discourages speculative thinking about hypothetical events. Issues are discussed from the legal and ethical aspects after they have occurred. We therefore cannot engage in a detailed discussion of cloning until it has occurred and we see its implications in practice.

 

QUALITY OF LIFE

The issue of quality of life arises in the case of cloning if ever it becomes a reality. The product of cloning will not have the same quality, as we know it in humans today. This is because a human is both matter and spirit. During the first trimester of intra-uterine development the soul, God inserts ruh, into the body. There is one ruh for each being. Thus the cloned product cannot have a ruh and will therefore not be human being, as we know. The product of cloning will have all the biological properties of the ordinary human being but will not have the spiritual qualities. Thus the life of the cloned product will be of little or no quality. We can only speculate how that cloned product will behave. The possibilities are frightening as the brave new world of biotechnology unfolds.

 

B. MEDICAL BENEFITS

Supply of organs for transplantation?

Preservation of progeny, hifdh al nasal?

Multiply gifted persons?

 

C. MEDICAL DANGERS

New diseases and problems

 

D. LEGAL –ETHICAL IMPLICATIONS

Inheritance: cloned son vs real son

Immortality: so no inheritance?

 

ETHICAL ISSUES

Human cloning although not yet achieved has already raised a lot of ethical controversies. The ethical debate on human cloning has been complicated be sensational media reporting. The public is not aware of the biological end ethical issues involved (4). The major ethical issues raised are: loss of human uniqueness and individuality, hazardous unexpected products from cloning, and criminal misuse of the cloning technology (2).

 

E. SOCIO-DEMOGRAPHIC IMPLICATIONS

Dignity of human if he is cloned like a plant

Monsters with no family background

Lineage, nasab, destroyed

Professor Omar Hasan Kasule Sr. November 2000