God knows what any female bears. He knows well to what extent the uterus may decrease and to what extent they may increase. To him everything is well measured and balanced. (Quran 13:8)

Reproduction and the ability to have children is a fundamental aspect of many people's lives. This great desire to be able to fulfill the basic human need to procreate has fueled the global technological revolution over the last half century in the context of artificial reproductive technologies designed to alleviate the effects of infertility. Reproductive advances such as in vitro fertilization (IVF), sex selection, reproductive cloning, and embryo selection for the purpose of creating “savior siblings” have all emerged as part of a rapid and ever‐changing branch of medicine. The next revolutionary breakthrough on the horizon is the prospect of uterus or uterine transplantation. This technology will appeal to many but could hold distinctive advantages to those of the Islamic faith since it will enable a couple with an alternative method of reproduction which allows them to have a genetically related child where the woman suffers from uterus factor infertility. At present the only other option would be surrogacy, which is forbidden in Islam. This article explores the scientific endeavors thus far made into this novel technology and how this advance may be received in the Islamic faith.

Reproduction, Islam, and Uterus Transplant Technology

(Bio)ethical Deliberations

In the UK alone, it is estimated that approximately 15,000 women per year who seek the help of fertility specialists are found to be incapable of becoming pregnant because of uterine factor infertility (Bosley ). Brangstrom notes that women who suffer from absolute uterine infertility are those that are (1) born with no uterus, a condition called Maayer‐Kutser‐Rokitansky‐Hauser (MKRH) syndrome; (2) women that have the lost the uterus through a hysterectomy, for reasons such as emergency obstetric complications, malignancy, or benign uterine disease; or (3) or women that have a deficient uterus in regards to implantation or pregnancy (Brannstrom et al. , 86). The purpose of uterus transplantation is to restore fertility to these women. For women who have functioning ovaries, the lack of a functioning uterus means they have no permissible way of gestating their own child to term or attaining motherhood. For other women, surrogacy may theoretically provide an alternative, but as outlined below this is far from an adequate alternative.

Uterus Transplants at This Experimental Stage Are Unsafe

With little data on potential outcomes some, such as Caplan, contend that it is unethical to transfer embryos into a transplanted uterus since “it is very likely that the first uterus transplant will fail” (Caplan ). Unsatisfied with Del Priore's comments (Del Priore et al. ) that the uterus can be removed if things go wrong, Caplan states:

But what if that uterus contains a fetus? What if the mother says she is willing to die to give birth to that fetus? What if the father or the mother say they want the uterus removed even if there is a fetus present if things are not going as planned? The doctors have not said as much as they need to about what their “exit” strategy will be if, sadly, the surgery does not go as planned.

At its experimental stages, a uterus transplant will raise concerns regarding the safety of the procedure. All novel methods of reproduction raise concerns, not least because potential harm to both mother and fetus may be unknown. Until a fetus is gestated in and born from a transplanted uterus, the success of the procedure will not be known. Yet the unpredictability of the procedure in its experimental stage should not of itself provide a sufficient reason to prohibit the technology. Coital conception can also pose risks. As Elsner comments, “we accept a woman has the right to bear a child by the traditional method of procreation knowing that it will have suboptimal health (e.g., as the result of a parent's genetically transmissible condition or the mother's health status)” (Elsner , 598). An analogy can also be drawn with IVF when it was in its experimental stages. When Edwards and Steptoe embarked on IVF they

could not be sure that developmental malformations would not occur. Indeed, noted ethicists had argued that IVF was unethical because of the risk that resulting children might be born damaged (Kass , 18–56). They condemned the selfishness of couples who were so bent on having children that they were willing to risk the birth of handicapped children. (Robertson , 939–1041)

Elsewhere it has been noted how:

Several years of failed attempts—including one attempt that resulted in an ectopic pregnancy in 1976—preceded the first successful replacement of an IVF embryo into a recipient's uterus. Furthermore, intracyto‐plasmic sperm injection, which currently “accounts for nearly half of all assisted reproductive treatments in the United States,” was introduced without an experimental phase “partly because animal models were thought to be unsuitable.” (Elsner , 598)

Determining whether an experimental reproductive technology is acceptable will be dependent on the level of risk posed to offspring as compared to the benefit, and thus will necessitate a risk/benefit ratio calculation. As with many new medical treatments, in the initial stages there will be some risk involved. This necessitates setting a base for safety; for instance, if the procedure has a 20% risk of failure and 40% risk of serious harm to the fetus, would this be regarded as too high to justify proceeding? Whether the risks to offspring being gestated in this fashion are justified will be a question policymakers and governments in the relevant countries must decide, taking account of the risks posed to the offspring, the “liberty interests of individuals needing assistance and to the moral responsibility of providers who decide whether or not to offer their services” (Robertson , 9). In the context of uterus transplantation some of those working within the field have already undertaken such an assessment and they have been inclined to proceed, as is evident by the recent attempt in Turkey.

Precautions can also be taken, such as prenatal diagnosis, to monitor the development of the pregnancy and healthy growth of the fetus. Measurements of heartbeat and fetal scanning by ultrasonics can detect abnormalities of the head, limbs, and other organs, and three‐dimensional ultrasound images enable clinicians to view images of the fetus. Safety concerns by themselves do not justify prohibiting a future procedure, providing the risk of harm is minimal when compared to the potential benefits. Thus safety concerns per se do not provide sufficient reason to bar this procedure. As noted above, the clinical team in Turkey plans to implant an embryo into the uterus transplant recipient this year and achieve a successful pregnancy through this novel technique.

Uterus Transplant Surgery Offers a Better Alternative to Surrogacy

For a woman lacking a functioning uterus the only way genetic motherhood can be achieved is through surrogacy. Surrogacy, even in the West, in those countries where this practice is permitted such as the United Kingdom, is problematic. Surrogacy can be an emotionally draining method of founding a family and is shrouded in legal uncertainty. For instance, in the United Kingdom, surrogacy agreements are not legally enforceable and it is the woman who gives birth to the baby who is regarded as the legal “mother” (The Human Fertilisation and Embryology Act 2008, s33(1)). Thus, there is always the risk that the surrogate could renege on the agreement: she may decide to keep or abort the child. Highlighting the difficulties surrounding surrogacy, Rosenfel explains why a surrogate may change her mind:

The consent that the birth mother gives prior to conception is not the consent of…a woman who has gone through the chemical, biological, endocrinological changes that have taken place during pregnancy and birth, and no matter how well prepared or well intentioned she is in her decision prior to conception, it is impossible for her to predict how she will feel after she gives birth. (Andrews , 162)

As a method of founding a family, the practice of surrogacy continues to generate legal and ethical debate in the United Kingdom. Winslade summarized why there is a reluctance to accept surrogacy: “The practice has a potential for economic exploitation, moral confusion and psychological harm to the surrogate mothers, the prospective adoptive parents and the children” (Winslade , 153). In A v C [1985] FLR 445, one of the first cases involving a surrogacy arrangement to come before the English courts, the judges were unanimous and explicit in their condemnation of surrogacy; Justice Ormrod commented that the surrogacy arrangement was a “simple, logical but totally inhumane proceeding.” Lord Justice Cumming‐Bruce condemned the arrangement as “a kind of baby‐farming operation of a wholly distasteful and lamentable kind” and Lord Justice Stamp described it as an “ugly little drama” (Jackson , 873). In Re C (a minor) (wardship: surrogacy), Justice Latey referred to the “difficult and delicate problems of ethics, morality and social desirability raised by surrogacy.”

However, judicial attitudes do appear to have changed in more recent times. For instance, note Justice Baker's comments in the case of Re T (a child) (surrogacy: residence order) [2011] EWCH 33 (Fam) that “in recent years the practice of surrogacy—whereby a woman gives birth to a child for others—has been accepted as a method of enabling childless couples to experience the joy and fulfillment of parenthood.” Yet the practice remains problematic and the very case in which Justice Baker made those comments demonstrates the pitfalls with surrogacy as a method of attaining parenthood; in that case the surrogate reneged on the agreement and refused to hand the baby to the commissioning parents after the birth. Furthermore the case highlights how the law regulating surrogacy in the UK offers little protection to either the commissioning couple or the surrogate. In the section on religious deliberations below I discuss how surrogacy is not an alternative for Muslims because the practice is regarded as forbidden in Islam. Suffice it is to say that uterus transplant surgery holds major advantages over surrogacy; Brangstrom et al. cogently sums these up as follows:

The advantages of a model for a successful uterine transplantation compared to gestational surrogacy are obvious for the infertile couple—apart from the joy of experiencing a pregnancy, they would not be dependent on a third party during gestation and would have full control over maternal lifestyle‐influences on their offspring. Furthermore, the genetic mother, instead of the surrogate, would take the physiological risks involved with any pregnancy. Issues such as maternal bonding during gestation, the definition of motherhood and the risk of economic pressure being a factor in recruitment of the surrogate carrier, would be abolished. Also, the prospected child would not have to deal with the possible conflict of having two mothers. (Brannstrom et al. 2003, 177–84)

A uterus transplant would allow women the opportunity to gestate and experience pregnancy. Just as endeavors to assist women overcome other forms of infertility such as IVF, surgical sperm retrieval, and embryo transfer have become widely acceptable, women lacking a functioning uterus are suffering from a form of infertility. Thus there is a persuasive case to be made in the West that uterus transplantation should be regarded no differently than other forms of fertility treatment. Just as IVF assists couples having difficulty in conceiving, uterus transplantation will assist women having difficulty gestating.

Research demonstrates that many women do attach importance to the experience of gestation and pregnancy (Thornton et al. , 87–92). Altchek explains why gestation is deemed to be of such importance to women:

For many women, the ability to become pregnant can be very important. For them, childbearing fills a deep emotional and social need, and they may feel a corresponding sense of loss if they are unable to conceive and give birth. It is likely that for many women the intense desire to become pregnant is, at least in part, an innate feature of evolutionary biology. But there may be a stronger social component to this desire. Historically, in many cultures, to be barren was to be cursed. Having a child, on the other hand, meant that one was blessed and honored, perpetuating a family and a name. (Altchek , 154)

In light of the importance of gestation to many women and the shortfalls of surrogacy as an alternative, there are strong grounds to allow uterus transplant technology as clinical treatment to enable women to overcome uterine factor infertility. Surrogacy, adoption, and foster care offer no better alternative. They do not compensate for the inability to gestate one's own child.

Resources

Despite the recent resurgence of uterine transplantation research, the gain is very limited because few research groups are dedicating their resources to this challenging and relatively new area in reproductive medicine. (Bedaiwy et al. , 2031–55)

In a country such as England which has a publicly funded healthcare system and limited budget, some form of rationing policy must operate. The National Institute for Health and Clinical Excellence (NICE) provides one way in which treatments can be rationed by examining the increase in health likely to accrue as a result of introducing a new treatment—the so‐called incremental cost effectiveness ratio (Mason and Laurie , 442–43). This is measured by the cost per quality adjusted life year (QALY).

Limited resources might have thus far delayed success in achieving a breakthrough in uterus transplant technology. The success of the IVF technologies may have negatively affected investments in this more recent endeavor, and now that it has become apparent that the IVF technologies do not present a solution for some infertility cases, uterus transplants appear to have resurfaced on the bioethical agenda. Arguments that uterus transplantation should not be publicly funded or invested in because it is not medical treatment needed to preserve life, can be rejected by reference to the fact that treatments are often permitted and invested in medical procedures that are not life‐saving. Consider kidney transplantation which will significantly improve a patient's quality of life, and yet dialysis is accepted as a life‐preserving alternative. Cornea transplants to restore the sight of people with clouded vision is also now a well‐accepted therapy, and it is performed only to improve a patient's quality of life, not to preserve it. Finally, fertility treatment is offered in the United Kingdom by the National Health Service, and it is worth recalling how the Warnock Committee “took the view that actions taken with the intention of overcoming infertility can, as a rule, be regarded as acceptable substitutes for natural fertilization” (Report of the Committee of Inquiry into Human Fertilisation and Embryology ). This was accepted by the government, and since April 2005 women between the ages of 23 and 39 are able to get one free IVF cycle through the NHS. NICE guidelines published in 2004 recommended that this be increased, so that suitable couples receive up to three free cycles of IVF treatment from the NHS.

Uterus transplantation, after it has proved a successful method of reproduction, should similarly be made available for women suffering from uterus factor infertility, just as other forms of medical treatment to treat infertility are made available. As the Warnock Committee stated:

There are many other treatments not designed to satisfy absolute needs (in the sense the patient would die without them) which are readily available on the NHS. Medicine is no longer exclusively concerned with the preservation of life but with remedying the malfunctions of the human body. On this analysis, an inability to have children is a malfunction and should be considered in exactly the same way as any other…. In summary, we conclude that infertility is a condition meriting treatment.

These arguments apply equally to uterus transplantation, which will help to create life and treat uterus factor infertility. At present, the costs of uterus transplantation are unknown, and it may be the case that it will be more expensive than IVF. While allocation of state funding is beyond the scope of this chapter, costs of this procedure could be limited by stating it is to only be available as an option of last resort in the face of a woman's clinical inability to bear a child. Access to this procedure could be limited by the implementation of eligibility criteria: for instance, that uterus transplants are only to be funded by the NHS where the woman/couple have no children and the woman is unable to reproduce because she lacks a functioning uterus which could be remedied by a uterus transplant. Just as it is widely accepted that it is legitimate to invest state funds into both organ transplantation (which in the case of kidney transplants is not life preserving) and fertility treatment; it is argued that NHS funding should also extend to helping women overcome uterus factor infertility.

Religious Deliberations in the Islamic Tradition

Why It Is Imperative that Islam Engages with These Advances and Contributes to the Discourse on the Matter

Conclusion: The Interplay of Islam and the West

Scientific advances attained in the West in the context of uterus transplantation surgery must not be disconnected from Islam and specifically Islamic bioethics. Whereas Muslims have been excluded from utilizing other advances in ARTs due to the importance of preserving the genetic code, uterus transplantation is one advance that Muslims may be able to utilize to help them achieve their desires of parenthood. What is now needed is for Islamic scholars to revisit and clarify the matter. The interplay of Islam and the West is important, not merely to inform religious scholars of the technical and ethical aspects that such biomedical advances may raise and facilitate such discourse between the two, but also because we must not forget that “the West” and “Islam” are not always two distinct separate identities. This is rhetoric which has come to characterize the dominant discourse surrounding the globalized “War on Terror” and the imperialist military intervention which lies at its core (Gilmore ). However, in the context of uterus transplantation, “Islam” and the “West” need not be mutually exclusive and are in fact intertwined. The first attempt at human uterus transplant occurred in Saudi Arabia, a Muslim country, and it was this surgery that provided the impetus for the later advances in the West. The second attempt in Turkey was also designed to assist a young Muslim couple overcome their infertility.

Furthermore, one can be Western and Muslim, and it is important that Islamic scholars reach out and open channels of communication with individuals who may be living as religious minorities in the West. Islamic scholars must not go “quiet” on the issue of uterus transplantation, especially now that it appears it is only a matter of time before it is offered as a clinical treatment in the West. Only when Muslims in the West are informed can they “speak up” when consulted by the government about prospective legislation governing such novel advances, thereby ensuring the Muslim voice is heard and thus represented.