Infertility is defined as the inability of a couple to conceive after 1 year of regular, unprotected intercourse. Natural cycle fecundity, or the chance of a couple conceiving in a given month, is 20–25 % for a healthy couple. Approximately 10–15 % of couples experience infertility, and after 1 year of trying to conceive it is appropriate to evaluate a couple for infertility [1].

Recent research has shown that suffering from involuntary childlessness may be nearly equally distributed between women and men, but men have more difficulty in communicating this emotional crisis [2]. The psychological impact of infertility is a complex, integral part of the condition which must be taken into account by all treatment services associated with assisted reproduction [3].

It is human nature to want to have children. The Qur’an says that “wealth and progeny are adornments for the life of this world,” [4] which means that families seek two things: to have a secure financial future and children. Because one of the prayers of believers described in Qur’an is “O, Lord, grant us spouses and offspring who will be the comfort of our eyes,” [5] seeking a cure for infertility is, thus, appropriate.

There are a few case scenarios depicted in the Holy Qur’an which helps us to gain a proper insight into the problem of infertility. The first illustrates the story of Ibrahim (May God give him His blessing) and his wife Sara as revealed in the Qur’an (surah 51: 28–30). “…And they (angels) gave him (Ibrahim) glad tidings of a son endowed with knowledge. But his wife came forward clamoring, she smote her forehead and said: A barren old woman! They said: Even so has thy Lord spoken and He is full of wisdom and knowledge.” The aged Sara had willingly resigned to her destiny of being infertile but yet continued to be firm in her faith and true to her husband. She remained a complete, faithful woman in every other way. And she offered Hajar to Ibrahim in marriage, so as to enable him to have children. She was ultimately blessed with a child, Ishaq.

As with the example of Ibrahim, Zakaria remained faithful and supportive of his infertile wife. In surah 21: 89–90, Allah says: “And (remember) Zakaria, when he cried to his Lord: “O my Lord! Leave me not without offspring, though Thou are the best of inheritors.” So We listened to him and granted him Yahya (John). We cured his wife (barrenness) for him. They were ever quick in emulation in good works; they used to call on us with love and reverence, and humble themselves before Us.” Being infertile does not make one any lesser a man or woman. Like Zakaria, one should beseech Allah for the blessings of offspring [6].

The Prophet PBUH says: “Marry the kind and fertile women who will give birth to many children for I shall take pride in the great numbers of my ummah” (Nation) [7]. Islam gives strong and unequivocal emphasis to high fertility.

Dr. Edwards, an embryologist and Dr. Steptoe, a gynecologist in the United Kingdom first pioneered the fertility technique called In Vitro Fertilization Pre-Embryo Transfer (IVF–ET). In July 1978, they announced to the world the birth of the first test-tube baby, Louise Brown which was a landmark achievement in the science of reproductive medicine [8]. Since then, a myriad of assisted reproductive techniques have surfaced, further refining and superseding earlier technologies [9].

The use of medical techniques to enhance fertility is a topical issue that cannot be overemphasized, as recent studies show that Assisted Reproductive Technology (ART) is responsible for between 219,000 and 246,000 babies born each year worldwide [10].

ART today is being used for many different objectives. First, is the employment of ART as a succor to childless/infertile couples.

Second, it is also used to enable women without a male partner to have children by using sperm provided by a donor. Furthermore, assisted reproduction is equally being employed for baby gender selection and the quest for a particular sex (male or female) by fertile couples who resort to IVF just to be able to have a preferred gender. It is also used to avoid genetic and chromosomal diseases by pre-implantation diagnosis (PGD).

Islamic law frowns on any use of ART with no medical justification. Self-imposed single motherhood or fatherhood, as with lesbians or gays longing for children, is a sharp negation of Islamic law provisions.

IVF is a process by which a woman, through hormonal manipulation simultaneously produces several ova. These ova are needle aspirated at the proper time under ultrasonic guidance usually through the vagina or through the abdominal wall. In the lab, the husband’s sperms fertilize these ova. Successfully fertilized ova (zygotes) reaching the four to eight cell stage are transferred into the uterus. At this point, the uterus has been prepared by hormones in order to begin implantation of the transferred zygotes (pre-embryos).

The current success rate, measured by fertilizations resulting in a live birth, is between 20 and 30 %. IVF, with its various modifications, i.e., GIFT (Gamete intra-fallopian transfer), ICSI (intracytoplasmic sperm injection) [11] etc., has been declared islamically permissible, only if the following conditions are satisfied. First, the IVF must involve a married couple. Second, the sperm must be from the husband, and the eggs from the wife. Third, this must occur within the context of a valid marriage. Fourth, the procedure must be conducted by a “competent team” in order to reduce the chances of failure or mixing of zygotes and pre-embryos of different couples when kept in liquid nitrogen. Fifth surrogacy is not accepted. Finally, no more than the appropriate number of fertilized eggs should be transferred to the uterus [12]. It is common to transfer only two to three fertilized eggs, although there are usually more fertilized eggs produced. Many centers transfer only one or two fertilized eggs.

Freezing the remaining fertilized ova is permissible by some Islamic Scholars as long as they are only used in subsequent cycles for the same couple, and the couple is still married. The fate of the unused eggs has not yet been decided upon. It is permissible to use them for medical research with the consent of the couple and within the appropriate guidelines. However, The International Islamic Fiqh Academy of Organization of Islamic Conferences (OIC-IFA) in 1990 refused the freezing of the pre-embryos as occurrences of mixing of gametes and pre-embryos happened.

Pregnancy outcomes after ART treatment are not generally as favorable as for spontaneous conceptions. A substantial proportion of this excess risk is mediated through iatrogenic multiple pregnancy, as multiple embryos are routinely returned to increase the chance of pregnancy. Accordingly, early pregnancy loss, total miscarriage rates and stillbirth rates are elevated compared with the general population.

For the mother there is a low risk of hyperstimulation of the ovaries which is a serious complication. There are also elevated risks for preeclampsia, gestational diabetes, placenta previa, placental abruptia, and caesarean delivery. Gestations for ART pregnancies tend to be shorter and birth weights of singletons and twins are substantially reduced to a degree that can be comparable to smoking throughout pregnancy. The reasons for this are uncertain [13].

We are now developing a clearer view of the longer-term implications of ART. Cumulative evidence from a variety of sources including population registries, cohort studies, and meta-analyses indicate that ART is associated with an increased risk of major congenital malformation, and that this risk appears to vary by treatment modality in addition to patient’s age and factors related to infertility.

The use of pre-embryo freezing appears to substantially reduce the risk, which suggests that the defects are in part intrinsic to the embryos, and that a freeze–thaw cycle adds a selection pressure against developmentally compromised pre-embryos [14].

Women undergoing IVF with multiple embryo transfer face an increased risk of twins and triplets. The social and economic consequences of multiple pregnancies are significant, as are risks to the mother and baby. Single Preembryo transfer can minimize the risk of multiples but the pregnancy and live birth rate was lower [15].

Multifetal pregnancy, particularly high-order multiple pregnancy, should be prevented in the first place because of its associated fetal and maternal complications and increased cost [16].

The teachings of the Qur’an and Hadiths have emphasized the vital role of the institution of marriage and the family structure, and inseparable from this is the act of procreation. To this effect Allah (God, Exalted be His Name) says in surah 16: 72; “And Allah has given you wives of your own kind, and has given you, from your wives, sons and grandsons, and has made provisions of good things for you. Is it then in vanity that they believe and in the grace of Allah that they disbelieve?”

Artificial reproduction is not mentioned in the primary sources of Shari’ah; however, when procreation fails, Islam encourages treatment, especially because adoption is not an acceptable solution. Thus, attempts to cure infertility are not only permissible, but also encouraged. The duty of the physician is to help a barren couple achieve successful fertilization, conception, and delivery of a baby [17].

All assisted reproductive technologies are permitted in Islam, if the semen source, ovum source, and the incubator (uterus) come from the legally married husband and wife during the span of their marriage [18]. According to Islam, a man’s or woman’s infertility should be accepted if it is beyond cure. Assisted reproduction was widely accepted after prestigious scientific and religious bodies and organizations issued guidelines, which were accepted by concerned authorities in different Muslim countries. These guidelines included a Fatwa from Dar El Iftaa, Cairo (1980) and a Fatwa from the Islamic Fiqh Council, Makkah (1984), the Islamic Organization for Medical Sciences (IOMS) in Kuwait (1983), the Fatwa of International Islamic Fiqh Academy in 1986, and the International Islamic Centre for Population Studies and Research, al. Azhar University. These guidelines are followed by most Muslims [19].

The dyad of the legal husband and wife must not be intruded by any third party. The involvement of a third person in the equation is totally unacceptable whether this take the form of a sperm, an ovum, an embryo or a uterus. Hence the widespread practice in ART facilities of sperm, ovum, and embryo donation and the “rental” of uterus is incompatible with the Islamic injunctions related to human reproduction [20]. Frozen pre-embryos are the property of the couple alone and may be transferred to the wife in a successive cycle provided the marital bondage is not absolved by death or divorce [21].

This ban on third-party assistance has been upheld in many fatwas and bioethical decrees Issued since 1980 in the Sunni Muslim countries [22]. For example, fatwas supporting assisted reproduction treatment but banning third-party assistance have been issued in Kuwait, Qatar, Saudi Arabia and the United Arab Emirates [23]. In 1997, at the ninth Islamic law and medicine conference, held under the auspices of the Kuwait-based IOMS in Casablanca, Morocco, a landmark five-point bioethical declaration included recommendations to prevent human cloning and to prohibit all situations in which a third party invades a marital relationship through donation of reproductive material [24]. Such a ban on third-party reproductive assistance of all kinds is now effectively in place in the Sunni world, which represents approximately 90 % of the world’s 1.6 billion Muslims.

Another form of ART is surrogacy. There are two types of surrogacy, partial and complete. In partial surrogacy, a couple will solicit or commission a woman to be artificially impregnated by the “husband” semen. The surrogate will then carry the pregnancy to term, and upon birth, give the baby away to the soliciting couple. In this case, the child will have the rearing father as the biological father, a rearing mother, and a biological birth mother.

In a complete surrogacy, the commissioning couple will undergo IVF. The embryo produced by IVF is transferred then to a surrogate woman. The surrogate gives the baby to the soliciting/rearing couple at birth. In this case, the biological parents are the rearing couple, and the surrogate is the birth mother [25].

Under Islamic law, surrogacy is prohibited [26]. Surrogacy between the wives of one husband is allowed by Ali Khamini of Iran.

The Fatwa of the Islamic Fiqh council of Makkah in 1984 allowed surrogacy by replacing the embryos inside the uterus of the second wife of the same husband who provided the spermatozoa. In 1985, the council withdrew its approval of surrogacy [27].

Linguistically and Islamically, the Arabic word for “to give birth” is Walad, and for “mother” it is Walidah, or the “one who gives birth.” A verse from the Qur’an states that, “None can be their mothers except those who gave them birth” [28]. Even if there is an agreement between the parties, the confusion of lineage, which is inevitable in these surrogacy arrangements and which is of major importance in Islamic law, prohibits surrogacy. If surrogacy is still done despite the prohibition, it is the consensus of Islamic scholars that the birth mother is the “real” mother.

Major divergences in Islamic juridical opinion between Sunni and Shia religious authorities have led to striking differences in the practice of ARTs, particularly with regard to the use of donor gametes [29]. In the late 1990s, the Leader of the Islamic Republic of Iran, Ayatollah Ali Khamene’i issued a fatwa effectively permitting third-party donations including egg donation, sperm donation and surrogacy [30].

Iran is the only Muslim country in which ARTs using donor gametes and embryos have been legitimized by religious authorities and passed into law. This has placed Iran, a Shia-dominant country, in a unique position vis-à-vis the Sunni Islamic world, where all forms of gamete donation are strictly prohibited [31]. Most Shia scholars have also issued jurisprudential decrees (fatwas) that allow surrogate motherhood as a treatment for infertility, albeit only for legal couples [32].