## Abstract

The Middle East (ME), an area rich in history and tradition with >300 million population, includes 18 heterogeneous countries concerning resources, income per capita, available healthcare services, population density, growth rate, birth rate, total fertility rate and life expectancy. There is a high prevalence of infertility in the ME because of post-partum infection, unsafe abortion, iatrogenic tubal and pelvic infertility, tuberculosis, schistosomiasis and high incidence of male factor infertility. It is argued that in the ME, the solution to the problem of infertility is its prevention, and population control should take precedence over infertility treatment. However, for a successful family planning program and adoption of small family norms, couples should be reassured that they will be helped to achieve pregnancy should they decide so. Prevention and treatment of infertility are of particular significance in ME because a woman social status, her dignity and self-esteem are closely related to her ability to have children. Also there is gender suffering of infertility in the ME. One of the stumbling blocks to acceptance of assisted reproductive technology (ART) as a line of treatment of infertility was the unacceptability to the main religious groups of the involvement of a third party in the act of procreation. Practices of ART in the ME have many common features and little differences. A mechanism had to be found to provide low-cost ART to the needy.

The ‘Middle East’ definition used by the current international tax calculations and airfare determination as established by the International Air Transport Association (IATA) included as constituents of the Middle East (ME), Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Pakistan, Palestinian territories, Oman, Qatar, Saudi Arabia, Somalia, Sudan, Syria, United Arab Emirates and Yemen. The ME, an area rich in history and tradition, is also a land of contemporary economic and political struggle with >300 million population. It comprises a heterogeneous group of countries concerning resources, income per capita, available state supported healthcare services, population density, growth rate, birth rate, total fertility rate and life expectancy.

In the ME, the paradox is that although demographics in many countries in the region point to a struggle to control population growth, one of the highest fertility rates in the world are found in the ME countries where total fertility rate varies between 2 and 6.8 with most of countries above 3 (Population Reference Bureau, 2007) (Table I).

Table I.

ME countries: some demographic patterns.

Country Population mid-2007 (Millions) Birth per 1000 population Rate pf natural increase (%) Total fertility Rate GNI PPP per capita US$2006 1. Bahrain 0.8 21 1.8 2.6 18.770 2. Egypt 73.4 27 2.1 3.1 4.680 3. Iran 71.2 18 1.2 8.480 4. Iraq 29 36 2.5 4.9 — 5. Israel 7.3 21 1.5 2.8 25.470 6. Jordan 5.7 28 2.4 3.5 6.200 7. Kuwait 2.8 21 1.9 2.6 29.200 8. Lebanon 3.9 19 1.5 2.3 5.460 9. Pakistan 169.3 31 2.3 4.1 2.500 10. Palestine 33 2.9 4.6 — 11. Qatar 0.9 17 1.5 2.8 — 12. Oman 2.7 25 2.2 3.4 14.570 13. Saudi Arabia 27.6 30 2.7 4.1 16.620 14. Somalia 9.1 46 2.9 6.8 — 15. Sudan 39.6 33 2.2 4.5 2.160 16. Syria 19.9 28 2.5 3.5 3.920 17. UAE 4.4 17 1.5 2.7 23.990 18. Yemen 22.4 40 3.2 6.2 920 Country Population mid-2007 (Millions) Birth per 1000 population Rate pf natural increase (%) Total fertility Rate GNI PPP per capita US$ 2006
1. Bahrain 0.8 21 1.8 2.6 18.770
2. Egypt 73.4 27 2.1 3.1 4.680
3. Iran 71.2 18 1.2 8.480
4. Iraq 29 36 2.5 4.9 —
5. Israel 7.3 21 1.5 2.8 25.470
6. Jordan 5.7 28 2.4 3.5 6.200
7. Kuwait 2.8 21 1.9 2.6 29.200
8. Lebanon 3.9 19 1.5 2.3 5.460
9. Pakistan 169.3 31 2.3 4.1 2.500
10. Palestine 33 2.9 4.6 —
11. Qatar 0.9 17 1.5 2.8 —
12. Oman 2.7 25 2.2 3.4 14.570
13. Saudi Arabia 27.6 30 2.7 4.1 16.620
14. Somalia 9.1 46 2.9 6.8 —
15. Sudan 39.6 33 2.2 4.5 2.160
16. Syria 19.9 28 2.5 3.5 3.920
17. UAE 4.4 17 1.5 2.7 23.990
18. Yemen 22.4 40 3.2 6.2 920

It is often argued that in the ME with many low income and middle income countries (Table I), the solution to the problem of infertility in these countries is in the prevention of post-partum infection, unsafe abortion, iatrogenic infertility, tuberculosis, schistosomiasis and ST1s which are preventable causes of infertility in the ME (Serour and Hefnawi, 1982). In low-income countries where health service resources are limited and basic health needs are unmet, if health resources are used to provide expensive advanced technology for the treatment of infertility, the opportunity is lost for using these resources to deal with other serious health problems affecting mortality and morbidity of a large sector of the population of the country.

However, the physical and psychological burden the infertile couple go through and the financial cost couples are willing to pay, if they can afford it, attest to the high ranking of infertility as a perceived burden of disease, which should be alleviated by all means including assisted reproductive technology (ART) (Fathalla, 2002). Furthermore, for a successful family planning program and adoption of small family norms, the issue of involuntary infertility becomes more pressing. Couples who are urged to postpone, delay or widely space pregnancies should be reassured that they will be helped to achieve pregnancy should they decide so (Serour et al., 1991a; Serour and Omran, 1992; Fathalla, 2002).

ART, a necessary line of treatment for many cases of male and female infertility, was long debated in the ME whether should it be included in the armamentaria of infertility treatment or not. The use of ART to manage infertility is a contested issue in the context of the cause of the problem, the attitude to over-population and availability of scarce health resources. The challenge tasks will be to simplify ART in such a way that it becomes affordable in low and middle income countries in the ME. Simplifying should reduce the cost but not the quality, and special attention should be given to eliminating complications such as ovarian hyperstimulation syndrome and multiple pregnancy. Both complications are unacceptable in these countries (Ombelet and Campo, 2007).

## Medical issues in infertility in ME

The terms infertility, sterility, subfertility, childlessness and infecundity are often used loosely and differ substantially between demographic and medical usage. In demographic terminology, primary infertility is defined as the inability to bear any children either due to the inability to conceive or due to the inability to carry a pregnancy to a live birth after several years of exposure to the risk of pregnancy. In medical terminology, however, infertility is defined as the inability to conceive. Inability to conceive within 2 years of exposure to pregnancy is the epidemiological definition recommended by the World Health Organization (World Health Orgainzation, 1975, 2001). Clinical studies often use a 1 year period of exposure.

It is estimated that worldwide between 70 and 80 million couples suffer from infertility, most of these are residents of developing countries including the ME (Fathalla, 1922; Boivin et al., 2007). Only a limited number of papers reported on the prevalence of subfertility and infertility in developing countries including the ME. The prevalence of infertility differs tremendously between regions and between countries. The figures are as low as 9% in some African countries as Gambia (Sundby et al., 1998) or as high as 35% in Nigeria (Ebomoyi and Adetoro, 1990; Okonofua, 1996). The reported international prevalence of infertility ranges from 4% to 14% with a consensus estimate of ∼10% of married and cohabiting couples (Greenhall and Vessey, 1990; Thonneau and Spira, 1990; World Health Organization, 1991; Sciarra, 1994; Lunenfeld and Van Steirteghem, 2004; Larsen, 2005). In the ME, prevalence of infertility is expected to vary between 10% and 15% of married couples because of high prevalence of post-partum infection, post-abortive infection, iatrogenic infertility, schistosomiasis and tuberculosis (Serour and Hefnawi, 1982; Serour et al., 1991a, 1997). It should be noted that a prevalence calculation is subject of correct diagnostic process and registration modalities (Ombelet and Campo, 2007), both of which are very seldom present in many countries in the ME. Bilateral tubal occlusion is the most common underlying cause (World Health Organization, 1987; Nachtigall, 2006). Tubal and pelvic infertility is the leading cause of female infertility in many countries of ME. Several factors are responsible for the high prevalence of tubal and pelvic factors. There is a high prevalence of post-partum infection as more than 70 of all births in many countries in ME are attended by traditional birth attendants, and strict aseptic techniques are often not observed. High prevalence of unsafe abortion, iatrogenic tubal and pelvic infertility, tuberculosis and schistosomiasis are all contributing factors (Serour et al., 1991a, 1997; Serour and Hefnawi, 1982).

### Infertility and ART

ART is one line of treatment of tubal infertility and sometimes it is the only appropriate mode of treatment as in severe tubal damage, failure of conventional endoscopic surgery, severe male factor infertility and multifactorial infertility. Several studies in the ME had shown high prevalence of male factor infertility where ART is the most effective line of treatment particularly in severe cases of oligoasthenospermia (Mansour, 2004; Inhorn, 2006; Mansour and Abou Setta, 2006; Sills et al., 2007).

## Ethical issues in provision of ART

The ethical principle of justice implies that all people should have equitable access to healthcare services. However, because of the rapidly increasing cost of medical technology and advanced healthcare services in different fields of medicine, the question of resource allocation becomes a pressing and sometimes a decisive one (Serour, 2002). If the country has adequate resources and can provide basic health services as well as advanced healthcare services, as in some ME countries, there is no problem. However, in other countries in ME where resources are limited and basic health services are lacking, implementation of advanced healthcare services as ART, though it could benefit a certain sector of the population, could be unjust, because it deprives a major sector of the population of basic health services. In this context, there is a collision between the principles of justice and equity (Serour, 1997).

### Legislations and guidelines of ART

Statutes or law regulate the practices of ART in some countries in the ME as Israel and Saudi Arabia. In other countries, ART is regulated by guidelines as in Egypt. However, in some countries neither legislations nor guidelines exist to regulate various ART practices (Jones and Cohen, 2007). The social structure required to be accepted in ART programs varies in different countries in the ME. In Israel, marriage or stable relationship is required to be accepted for ART treatment. This permitted single women and lesbian couples access to ART treatment. In Iran and Lebanon, ART is permitted mostly for married couples. However, it is also permitted in some forms of temporary arrangements to provide oocyte donation, embryo donation or surrogacy. In most countries of the ME, a valid marriage contract is required before enrollment of the couple on ART programs. Violation of the marriage contract by death of one of the couple or divorce would prevent the use of gametes or embryos available in the ART center (Serour and Dickens, 2001; Serour, 2006).

### Insurance coverage

Cost was an important factor which hindered early establishment of ART centers in many countries in the ME, as some of these countries have limited health resources. In the 80s, the establishment of an ART centre with accepted international standards would cost about US$400 000–500 000 (Dandekar and Quigley, 1984). Today because of inflation and the rapid advancement in the technology of ART including new practices as preimplantation genetic diagnosis (PGD), cryopreservation and LASER applications in ART centers, the cost of establishment of ART center had increased by 3 or 4 folds. This relatively high cost limited the installment of such centers in governmental institutions in many countries in the ME till today. Most of the centers, in the majority of the countries in the area, are in the private sector. In low-income countries in the ME, many needy infertile patients cannot have access to ART in private centers as the cost of an IVF cycle is prohibitively expensive compared with the average income of many couples. The direct patient's cost per in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycle in the ME varies between US$ 0 and 4059 with an average of US\$ 2500 (Serour et al., 1991a; Sills et al., 2007; Shahin, 2007). Two studies in Egypt showed that 90% of patients felt the price was too high, 15–40% of patients could not afford to have the procedure and 40% only could afford to have a repeat cycle (Serour et al., 1991b; Shahin, 2007).

However, the cost of ART is totally or partially covered by the State in few countries. In Israel, there is a complete coverage of cost of ART for a number of cycles and in some other countries the cost is partially covered by the state (Jones et al., 2007; Sills et al., 2007). In Egypt, there are two large centers: one at Al Azhar University Hospital and the other at El Galaa Maternity Hospital Ministry of Health where the service is provided at a subsidized cost.

Government' subsidies of ART treatment in some of the ME countries show that because of importance and meaning of infertility treatment in the ME, national health policy has tended to favor public support of costly IVF programs (Birenbaum-Carmeli, 2004) even in some low-income countries as Egypt. A recent study from nine countries in ME had shown that the provision of such advanced technology is associated with minimal delay often <8 weeks (a range 0.3–3.5 months) from initial presentation to ART program (Sills et al., 2007).

## Patient's profile undergoing ART

Most couples undergoing ART in most ME countries are married couples with a stable marital relationship. In Israel, single women and lesbians have access to ART programs as well. Women's age group <29 years old and 30–34 years old constitute the largest age groups undergoing ART with a combined total of 59–64% of cycles (Mansour and Abou Setta, 2006; Sills et al., 2007). There is also a trend for IVF/ICSI in older women with 25% in the age group of 35–39 years. Women aged 40 and more represent 8.7–10.4% of all cycles performed (Mansour and Abou Setta, 2006; Sills et al., 2007). Most ART centers in the region do not have a policy of long-term follow-up of ART patients or the children born as a result of ART. However, few centers in some countries have implemented long-term follow-up policy of children born after ART and reported on the incidence of chromosomal aberrations and/or malformation in ART babies. Although all programs offered prenatal referrals outside their clinic by the end of the first trimester, 61.5% providers were involved in obstetrical care for their pregnant ART patients by attending them at delivery (Sills et al., 2007). This is in contrast to the practice in Europe and North America where the doctors performing ART are very rarely involved in delivery of these patients. Differences in patient comfort and satisfaction between the unified versus fragmented health provider approach have not been specifically studied from the perspective of the medical consumers and form a basis for further research (Sills et al., 2007).

### Number of embryos transferred

The financial difficulties often drive couples and the treating physicians as well to be inclined to request and apply the policy which leads to the highest pregnancy rate irrespective of the outcome of the pregnancy, i.e. the transfer of too many embryos (Serour et al., 1991b, 1998). In many countries in the ME, transferring too many embryos is still a common practice. A study had shown 25.9% of all women undergoing transfer received at least four embryos, 42% received three embryos and only 32.1% received two or one embryo (Mansour and Abou Setta, 2006). Transfer of too many embryos resulted in an exceptionally high rate of multiple pregnancy and high-order multiple pregnancy (HOMP) (Serour et al., 1998; Mansour, 2004; ICMART, 2006, Mansour and Abou Setta, 2006; Jones et al., 2007). Studies in the ME had shown that multiple pregnancy and HOMP vary between 28% and 32.6% (Serour et al., 1998; Mansour, 2004; Mansour and Abou Setta, 2006).

In 16 340 initiated cycles and 15 193 oocyte pick-up, the number of embryos transferred were one, two, three and more than three embryos in 10%, 24%, 39.4% and 26.6%, respectively. The incidence of twins and triplets and more was 27.4% and 5.2%, respectively (Mansour, 2004). In another study from 13 centers in nine countries in ME, the average number of embryos transferred was 2.4 (±0.4) for patients <35 years and 2.9 (±0.8) for patients >41 years. For these age categories, twinning was observed in 22.6 (±10.8)% and 13.7 (±10.4)%, respectively (Sills et al., 2007).

Because of the high incidence of HOMP, multifetal pregnancy reduction (MFPR) is widely practiced in many countries of the ME (Jones et al., 2007).

### Cryopreservation

Cryopreservation service is available in most centers in the ME. A study had shown that frozen thawed embryos were transferred in 17.2% of cycles performed in 13 ART centers in nine ME countries during the year 2005 (Sills et al., 2007). An earlier study showed that only 7% of transfers were from cryothawed embryos (Mansour, 2004) which may reflect a gradual increase in the use of cryopreservation in ART programs in the region. It is expected that installment of good cryopreservation programs in ART centers in the region would encourage physicians to minimize the number of embryos transferred per cycle and cryopreserve the surplus embryos.

### Micromanipulation

ICSI as a successful modality of treatment male infertility was introduced and widely practiced in the ME in the early 90s.

Studies from the ME had shown that male factor infertility is the most common indication for ART varying between 50.3% and 72.1% (Mansour, 2004; Mansour and Abou Setta, 2006; Inhorn, 2006; Sills et al., 2007).

However, ICSI is widely practiced in many centers in the ME for non-male factor infertility. A registry from 32 centers from eight countries in the ME showed a total of 15 193 aspirations during the year 2000, 13 533 (82.4%) and 1660 (17.6%) were subjected to ICSI and IVF, respectively (Mansour, 2004). During the year 2001, a Registry from 30 centers in nine countries in the ME showed of 13 979 oocyte aspirations, 12 684 (90.7%) and 1249 (8.9%) were subjected to ICSI and IVF, respectively (Mansour and Abou Setta, 2006). This represents an increasing trend in most ART centers in ME to use ICSI for virtually all causes of infertility and not only male factor infertility.

ICSI is widely used in ME to avoid the risk of failure of fertilization and because of the prevalence of male factor infertility (Mansour, 2004; Mansour and Abou Setta, 2006; Inhorn, 2006; Sills et al., 2007).

### Preimplantation genetic diagnosis

PGD is legally available in at least nine countries in the region. Sex selection for medical indications is performed in all countries where PGD service exists. However, sex selection for social indications, although is associated with a heavy demand in the region, is only performed in very few centers because of the ethical dilemma surrounding this practice (Serour and Dickens, 2001; Serour, 2006). In one country in ME, PGD for sex selection for social reasons had shown that the greatest demands were for male embryos to be transferred. In countries which provide such service, tight ethical guidelines are needed to avoid discrimination against the female child (FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health, 2006a; Serour, 2006).

Wide disparities exist in the quality, availability and access to infertility service in various countries in ME. However, several common factors can be identified in ART practices in the ME. Government registry or oversight of clinical IVF practice is limited or non-existing in most countries. None of the programs identified any local ordinance or regulations prohibiting advertisement of ART services to the public. Number of embryos transferred is fairly high, >2 or >3 embryos. MFPR is a common practice in ME. Sophisticated reproductive health service in ME is associated with a minimal delay. Most centers do not maintain a comprehensive IVF database. However, some independent agencies collect transnational data on IVF clinics (IFFS; ICMART; ME Registry, MER). However, all these bodies cover only a small number of ART centers which markedly flourished in ME during the past few years (Table II).

Table II.

ART Practices in some ME countries.

Country No. of centres Guidelines/statutes Requirement for ART Coverage or reimbursed Gamete donation
1. Bahrain Guidelines Marriage coverage Not allowed
2. Egypt 50–51 Guidelines Marriage No coverage Not allowed
3. Iran No data Statutes Marriage NA Allowed
4. Israel 24–27 Guidelines/statutes Marriage or stable relationship. Permitted for single women and lesbian couples ± complete Allowed
Jordan 16 Guidelines Marriage No coverage Not allowed
Lebanon 13 Guidelines Marriage No coverage Allowed
Qatar NA Guidelines Marriage Coverage Not allowed
Saudi Arabia 23 Guidelines/statues Marriage Coverage Not allowed
Syria Guidelines Marriage No Coverage Not allowed
10 UAE Guidelines Marriage Coverage Not allowed
Country No. of centres Guidelines/statutes Requirement for ART Coverage or reimbursed Gamete donation
1. Bahrain Guidelines Marriage coverage Not allowed
2. Egypt 50–51 Guidelines Marriage No coverage Not allowed
3. Iran No data Statutes Marriage NA Allowed
4. Israel 24–27 Guidelines/statutes Marriage or stable relationship. Permitted for single women and lesbian couples ± complete Allowed
Jordan 16 Guidelines Marriage No coverage Not allowed
Lebanon 13 Guidelines Marriage No coverage Allowed
Qatar NA Guidelines Marriage Coverage Not allowed
Saudi Arabia 23 Guidelines/statues Marriage Coverage Not allowed
Syria Guidelines Marriage No Coverage Not allowed
10 UAE Guidelines Marriage Coverage Not allowed

NA, not available.

Source: Middle East Registry, 2006; Collaborative transnational pilot survey of IVF in the ME 2007 and IFFS surveillance 2007.

## Socio-cultural aspects of infertility

Prevention and treatment of infertility are of particular significance in the ME area because a woman' social status, her dignity and self-esteem are closely related to her ability to have children. Childbirth and rearing are regarded as family commitments and not just biological and social functions. Furthermore, adoption as a possible solution to the problem of infertility is not widely acceptable in the region of the ME for various cultural and religious reasons (Serour et al., 1995).

There is gender suffering in infertility in many of the ME countries. Women are often blamed for infertility even if they are not the cause of infertility. If infertility occurs, it is the female partner who is anxious, frustrated and suffers from grief, fear, marital distress, domestic violence, economic deprivation, social stigma, community ostracism, divorce, polygamy and may even undergo life-threatening medical intervention (Serour, 2002).

In all modalities of treatment of infertility except ART, conception occurs only after sexual act between the male and the female partners and is not of particular ethical concern in any of the countries in the region. With the advent of ART since the birth of Louise Brown in UK on 25 July 1978, it became possible to separate the bonding of reproduction from sexual act (Steptoe and Edwards, 1978). ART enabled women to conceive without having sex. This challenged the age-old ideas and provoked discussion all over the world including ME. When ART was first introduced in ME, there was a tremendous societal rejection based on social, cultural and religious backgrounds.

The introduction of ICSI in ME for male infertility played a role in the change of attitudes of many couples to ART. Husbands in the structure of the family in many countries in the ME are usually more influential in decision-making in family affairs particularly reproduction. When the female factor was the cause of infertility, husbands often had been reluctant to seek medical advice, especially when the treatment was not conventional. Husbands were very reluctant to participate in or to agree to their wives to undergo ART for female factor infertility. Also, the fact that polygamy in some countries in the ME is a possible solution for husbands to father children if the wife was the cause of infertility made many husbands reluctant to agree to undergo ART, especially in the rural areas. However, when ICSI was introduced, it offered great hope to many infertile men, especially those with severe oligoasthenospermia or azoospermia. Husbands became very enthusiastic about ART and they took the initiative and encouraged their wives to undergo this new modality of treatment once it became available. The objections and resistance of the males to their wives to undergo ART almost disappeared. This encouraged many couples in the area to make use of ART for the treatment of their infertility (Serour, 2002).

In a part of the world like the ME, where the three major religions, namely Judaism, Christianity and Islam, emerged, religion still means and influences a lot of social behaviors, attitude, practices and policy making (Serour, 2000).

## Religious aspects of infertility in ME

One of the stumbling blocks to acceptance of the ART was the unacceptability to the main religious groups of the involvement of the scientist in the act of procreation (World Health Organization, 2003). The handling of the human gametes in the laboratory by the scientists in the process of conception created the most bizarre and inconsistent attitudes in many countries all over the world and particularly in the ME area. The Jewish attitude to infertility treatment is based on the fact that the first commandment from God to Adam was ‘Be fruitful and multiply and replenish the earth and subdue it’ [Holy Bible: 1:28(1)]. This is expressed in a Talmudic saying from the second century, which says ‘Any man who has no children is considered a dead man’. This attitude arises from the Bible itself and refers to the words of Rachel to Jacob, who was barren, ‘Give me children or else I die’ [Holy Bible: 30:1(1)].

The Mishnah emphasizes that only prohibitive, strict decisions require juridical substantiation whereas permissibility or leniency needs no supportive precedent. Some individual rabbis have taken a strict position, and suggested that legal and biological ties be severed with the removal of the oocyte from the body, but both chief Rabbis of Israel (of Ashkenazi or European origin and Sephardic/Oriental origin) support ART.

In general, there is near unanimity of opinion that the use of semen from the husband is permissible and masturbation should be avoided if at all possible, and coitus interruptus or the use of a perforated condom seems to be the preferred methods for provision of sperm. All orthodox Jewish legal experts agree that sperm donation using the semen of a Jewish donor is forbidden, but some rabbinical authorities (reform and conservative) permit sperm donation when the donor is non-Jew. Oocyte donation is acceptable, as only the offspring of a Jewish mother may be regarded as a Jew. Donation is also permitted for single women. Cryopreservation of embryos is permitted with the consent of the parents for a period of 5 years, which is renewable if requested by the couple. In case of death of the husband (or of divorce), the embryos may be transferred to the wife within 1 year after death of her husband, if supported by the recommendation of a social worker (or written permission in case of divorce) (Schenker, 2005).

Jewish religion does not forbid the practice of surrogacy, whether complete or partial, as indeed the practice is described in the Bible in the case of Sarah and Abram with Hagar who bore Abram a son, Ishmael, and Rachel, who used her slave girl Bilha to bear a child for Jacob as indicated in Genesis 19 and Genesis 30. Halachic authorities would allow fetal reduction, if it is absolutely certain that all fetuses would be lost otherwise. Some fetuses are being sacrificed in an attempt to save the others.

Christianity does not speak with one voice on infertility treatment and the technology of ART. What some would permit and regulate others would forbid. Rome puts absolute value on an unbreakable nexus between the fully human contest of the conjugal act and conception. Although it permits all conventional lines of treatment of infertility, it forbids to its members all practices of ART as they bypass the sexual union of man and woman (Donum Vitae, 1987). Although ART is not accepted by the Vatican, it may be practiced by the Protestant, Anglican and other Denomination's.

In the Protestant Churches, moral reasoning is the perennial task, establishing the acceptable limits in the application of new developments in science and technology, including ART (Dunstan, 1996). It is thought that infertile people have a proper claim on medical technology, and must be informed and counseled as they are vulnerable and therefore prone to exploitation.

Many protestant churches would allow ART with spouse gametes and no embryo wastage. The Eastern Orthodox Church does not oppose ART for couples. However, gametes donation or surrogacy, like the church of Alexandria, are not approved (Serour 2006).

In Islam, the primary sources of Sharia encouraged marriage, family formation and procreation (Holy Quran: Sura El Shoura: 49–50; El Nahl: 27; El Raad: 38). Thus, infertility management and its prevention to preserve humankind are encouraged in Islam [Gad El Hak AGH (H.E.), 1980]. ART was not mentioned in the primary sources of Sharia; however, ART within the frame of marriage was encouraged by the secondary sources of Sharia, in otherwise incurable infertility. It was not until Fatwas from Al-Azhar in 1980 (Gad El Hak AGH (H.E.) 1980), the Islamic Fikh Council in Mecca in 1984 and the Church of Alexandria in 1989 (Gregorios, 1989) that the procedure gained popularity and became widely acceptable to the medical profession, patients, religious leaders and policy makers in most countries of the area. These bodies and organizations issued guidelines which were adopted by the National Medical Councils and Ministries of Health in the various countries and controlled the practices of ART centers (Serour, 2002).

The guidelines encouraged couples to seek infertility treatment including (ART), as long as there was a medical indication for its use. Most of the guidelines indicated that gametes of a third person should not be used and the fertilized oocytes should be transferred to the uterus of the wife from whom the oocytes were obtained within a valid marriage contract. Oocyte donation, sperm donation, embryo donation or surrogacy were not allowed in most of these guidelines.

The Islamic Fikh Council of Mecca previously allowed surrogacy to be performed on the second wife of the same husband (Proceeding of the 7th meeting of Islamic Fikh council, 1984). The council soon after denied surrogacy and the guidelines became identical with those of Al-Azhar. The promulgation of these guidelines was just a response to the needs of the community, and the discussions and debates which arose in the area, as well as the problems anticipated with the practice of surrogacy with special reference to the cultural and religious background of the people in the area (Serour, 2002). The Shi'aa Guidelines has ‘opened’ the way to a third-party donation, via Fatwa from Ayatollah Ali Hussein Khomeini in 1999. This Fatwa allowed third-party participation, including oocyte donation, sperm donation, embryo donation and surrogacy. Recently, there has been some concern about sperm donation among Shi'aa. All these practices of third-party participation in reproduction are based on the importance of maintaining the family structure and integrity among the Shi'aa family.

These guidelines and legislation played a major role in comforting patients and physicians. In the 80s, seeking ART for infertility treatment was associated with secrecy, feelings of shame, doubt and even sometimes guilt, but in the 90s such feelings were replaced by openness about seeking infertility treatment and ART in particular (Serour et al., 1991a).

Most of the observant believers of the three major religions in the ME countries abide by these guidelines. However a small minority, which cannot be estimated, may ask for some modalities of ART outside this frame as oocyte donation, embryo donation or surrogacy. It becomes an ethical obligation of the treating physician to refer them where they can have this treatment provided if he/she has conscientious objection to provide such evidence-based treatment (FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health, 2006b).

## Conclusions and recommendations

Infertility does not threaten the life or endanger physical health. However, as health is not merely the absence of disease or infirmity and is a state of complete physical, mental and social well-being, infertility sufferings are very real. As fertility and childbirth are of particular significance in the ME, it is recommended that:

• Women should be empowered so that when infertility occurs they are not to suffer from its consequences including economic deprivation, social isolation, unstable marriage, domestic violence polygamy, stigmatization and even ostracism.

• Reproductive health education and improvement of the standards of basic healthcare services would prevent a substantial part of infertility.

• Infertile couples present levels of distress should be assessed by psychologists and coping strategies should be assessed prior to initiating treatment to provide the couple with opportunities to learn and practice new adaptive behaviors. This could enhance their ability to cope with infertility and the associated medical procedures.

• Efforts should be made to convince governments to include treatment of infertility and ART in their health service programs. Infertility treatment and its prevention serves rather than conflicts with population control policy.

• Ethicists, physicians, scientists, psychiatrists, social scientists, consumer's groups and religious leaders should have continuous updated dialogue and debate about development and new knowledge in ART. This would help to revise old guidelines and develop new guidelines.

• Reproductive medicine physicians should be aware of ethical issues involved in ART. When offering this service for their patients, it is the duty of the physician to provide the needs of his/her patients according to patient's ethical percept if this does not conflict with the accepted standards of healthcare. If the physician has a conscientious objection to treatment, it is the duty of the physician to refer the couple to where their needs can be met.

• Every effort should be made to reduce ART cost. The service to the needy may be provided through: donation, charitable projects, drug companies, research projects, health insurance and low cost IVF. Satellite clinics may cooperate with ART centers in larger cities to reduce the cost of establishing, many ART centers and reduce the overhead cost for the patients.

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