Introduction:

Iran is Nearly among the countries with the most access to health services. Nearly 80% of Iranian mothers have access to health services for women and children¹, this is while many countries in the world cannot provide such services to a large extent². In the past 30 years, there has been a remarkable improvement in reproductive health indicators in Iran³. Improving living standards in recent decades Establishment of a health care system and the provision of free primary health care has improved many health indicators, including maternal mortality, family planning, and childbirth by the trained person and at the hospital⁴. But social convention of marriage at an early age, especially in rural communities in the pregnancy and childbirth at a young age, higher fertility, low literacy levels, lack of education, women's reproductive rights are a serious threat. Islamic Republic of Iran to its obligations in the World Conference on Population and Development was included successfully acte⁵.. The delivery rate of adolescents pregnancy has fallen from 94 per thousand women to 35 per 1,000 women and fertility rates have risen from 5 per 2 per woman³. In spite of its impressive successes, there are still some shortcomings. For example, although the number of reproductive health services is sufficient, quality of service is not optimal and is below the standard in terms of ethical coverage of the profession^6..

Considering the importance of this issue, if the health system does not seek to improve reproductive health indexes in an ever-increasing number, the country will see a negative development in fertility rights, which is one of the most important components of human rights⁷. Reproductive rights are a part of human rights recognized by all countries and referred to in international human rights instruments, which include: the enjoyment of basic rights for each couple including: The right to safe pregnancy and childbirth through access to appropriate health services, the right to decide freely on the number of children and the interval between births, the right to information and education, family planning, The right to make decisions without violence, coercion and discrimination in relation to reproductive health and the right to enjoy the highest standards of reproductive health. according to the definition of WHO, is the physical, psychological and social well-being of all matters relating to the system of fertility and Its function⁸.

Traditionally, reproductive rights have been less than reproductive health issues and in many cases have been legalized in the fields of medical ethics or medical education. But in today's world, human rights principles can be seen in health and medical management as well as in national decision-making levels⁶.

Among these, midwifery, nursing and laboratory science are medical sciences that relate to the physical, psychological and social care of women during pregnancy, childbirth and postpartum. Midwives, nurses and laboratory personnel have a role to play in promoting the fertility of the community, protecting and promoting maternal and child health. It seems that the ill-treatment caused by violations of reproductive and sexual rights is a significant part of the burden of disease in men and women of reproductive age⁹. Due to the emergence of the concept, the breadth of the structure and the challenges in realizing reproductive and sexual rights, the present study was conducted with the aim of reviewing the ethics of fertility.

Method:

In this structured review, all studies conducted within the country during 2009-2018 using ethical keywords in fertility, ethical challenges and meta-analyzes of the country's information banks included Magiran- medlib-SID-iranmedex and Latin databases like CINHAL-Pubmed-scopus were examined and the data were analyzed by meta-analysis method; the data of the selected articles were collected.

All papers were reviewed regardless of location and place of publication and how they were done. After reviewing and compiling all the articles, the articles were duplicated and unrelated. In the next step, the articles were examined based on the criteria for entering the study, which included descriptive studies that somehow examined the ethical challenges in terms of fertility. Excrusion criteria included data from case reports and posters, conferences, and review articles. All the ethical issues necessary for the correct use of the extracted articles and the standards for publishing the work have been observed.

Findings:

After searching for databases and extracting a large number of articles based on the title and abstract, 220 articles were investigated, 193 were excluded due to the fact that they did not examine the ethics of fertility. 27 articles were examined more precisely of which 7 papers were devoted to legal issues in this area. Finally, 20 articles were reviewed in this review (PRISMA chart).

Finally ethical challenges were discussed in five areas: fertility, interpersonal relationships, education, abortion and constraints on fertility.

Fertility aid

The advancement of knowledge and technology in the present age has had an increasing impact on infertility treatment. Infertility treatment methods can be divided into two broad categories: "Non-interventional treatments" and "Third-party intervention therapies". Third-party intervention involves the use of methods for the treatment of purely cellular or physical components of the applicant's couples and does not require the intervention, such as IVF, IUI, ZIFT, and GIFT However, in treating treatments with third-party intervention, couples applying for treatment should benefit from the cellular or physical components of the individual or others. The donation of the embryo is a donation of gametes (sperm or ovum) and substitute uterus.

Apart from medical matters, fertility is nowadays considered as a facilitating process for the motherhood of women who are not currently willing or able to this experience. Unlike men who are capable of producing sperm during their life, women's bioavailability does not have this magnitude and the increase in age has a reciprocal relationship with pregnancy. The girl baby is born at birth with full reproductive capacity, with an approximate level of one million follicles, which declines to 300,000 after adolescence, and this downward trend increases as age rises. It has now been proven that the second decade of women's life is the best biological time to become pregnant. Because in the third decade, especially in the middle of this period, this continuous gradual decrease, called the atresia, increases.

[In this regard, two points are important. Because applicants are afflicted with certain diseases, according to Caution 1, the positive and negative effects of their, should be evaluated and informed as much as possible, so they can make informed decisions based on information and conditions of their illness. In other words, the special status of these people and the modernity of the methods emphasize the patients informed consent. This moral challenge refers to the fate of the egg, ovarian tissue, and especially the embryo after the death of the patient. Therefore, before advising on these methods, the patient should be consulted and given information so that he / she can make a proper decision based on his / her beliefs and goals. Hence, the need for informed consent is felt here^9,10,37,38.

Today, due to various social and cultural reasons, the tendency of women to form a family and, consequently, childbearing in the lower ages has decreased, and motherhood has not been among the primary goals of many women, and academic achievements and career advancement, or the acquisition of different experiences in young ages has a higher priority. On the other hand, women's reproductive capacity decreases with increasing age, as indicated. Hence, the number of women who are inclined to maintain the current fertility potential for future use is increasing. This phenomenon has led to the emergence of many ethical views on the rejection or acceptance of the use of reproductive methods in social terms.

Husbands provide third-party involvement in the reproductive process by providing eggs, sperm, embryos or uterus. Husbands reproductive techniques have opened the way to various other methods, including gender selection, pre-implantation genetic diagnosis (PGD), genetic manipulation, freezing of gametes, fetuses and gonads simulations¹¹.

However, the prescription and sanction that the principal requirement of this type of contract (the successional mother's obligation to carry a child to the benefit of the applicant's couples and the surrender of the child born to him) is in some ways defensible. The relevant arguments are not capable for proving the prohibition of all forms and examples of the use of surrogacy, as long as they can not prove their prescription^12,31,35. These issues have led to restrictions in various religions, taking into account medical ethics and the rights of mother and child, to impose restrictions on medical treatment. In many European countries, such treatment is prohibited after 40 years. Unfortunately, there are no specific laws in Iran, and according to the law, the donation of oocytes and embryos to patients undergoes treatment without restriction. The incidence of various complications, anesthetic risk and etc. can be seen frequently.

Among the most important ethical challenges in this regard are as follows:

1) Duration of the embryo storage: There is no scientific specific term for maintaining the embryo in a frozen state. In a recent report, Embryo has been freezing after 20 years and has led to a healthy baby. But because of the need for laboratory equipment, space and manpower, no center can hold embryos for a very long time. The use of these fetuses also decreases over time. The duration of this contract is subject to legislative regulation.

2) The fate of the fetus after the termination of the contract: the period of frozen embryo storage is completed on a day. Or for other reasons, such as the parent's request or non-payment of maintenance costs, the frozen uterine storage contract is terminated. Now we have to decide on the fate of these embryos. These embryos can have three fates: use in research can use these embryos in stem cell research, genetics and embryology.

3) Post-mortem fertility: It happens many times that while infertile couples have several embryos in liquid nitrogen reservoirs that are frozen and await their use, suddenly one of the couples or the wife dies and the surviving person has a child Getting out of your fetus.

4) Embryo ownership: Although embryo's tax is not entirely agreed upon and the laboratory's embryonic character is also disputed, the most important issue now is who can decide for the fetus? Are the couple alone, the wife alone, and can both of them make this decision is it possible to provide a lawyer to another?

5) Husband remarriage: According to the laws of Islam and Iran, polygamy is permissible for a man. Husband can use his first wife's fetus for the second wife's pregnancy, both the principle of the problem and the consent of the first wife of both are present.

6) Use of a laboratory embryo for the treatment of infertility: It may take some time from embryo cessation until embryo transfer. Therefore, for the use of embryos, it is always necessary to re-examine the couples and provide a re-consent satisfaction from both couples.

7) Clarity of contractual obligations: Obligations of the health center, such as insuring the embryos against natural disasters, the probability that the embryos will die after the freezing, and the non-commitment of the center for the transfer of the embryos under any circumstances and the obligations of the requesting couples, such as timely payment of the costs Clear and obvious^14,36.

Interpersonal relationships

Each discipline, based on the relationship between the patient and the treatment staff, gives rise to various examples of ethics and professional commitment. Since counseling services are open to many diseases and are part of ongoing treatments, the nurse or midwife as a therapist is required to observe ethical principles in dealing with the patient.

Therefore, ethics finds a special place in counseling with infertile couples that are discussed, such as:

1) Autonomy: Getting treatment and denying treatment is the right of each patient, provided that there is adequate information about the disease, complications and treatment. This requires the need for informed consent. But since the child-rearing process is dependent on two people, counseling about parenting and routine therapy should be done with both, and decisions should be taken freely on both sides.

2) Privacy: Privacy in all cases should be kept to the level of couples and individual privacy can not be observed.

3) Truth: In many cases, parent deficiencies interfere in the child's future life, such as widespread disabilities or chronic illnesses or end-ends, in which case the counselor should provide the couple with the fullest of the facts.

4) Alternative donation and donation methods: There is a lot of psychological burden on the family and need consultation in several sessions to ensure that the child is considered as a true child of the family.

5) Gender selection: The nurse or midwife is committed to ask the couples asking for all aspects of this practice and its complications, and psychologically verifying the necessity for doing^15,16.

Education

The concept of reproductive and sexual rights refers to the ability of all individuals to regulate fertility and to enjoy a secure and satisfying bilateral relationship, free of discrimination, coercion and violence. In fact, many ethics and ethics philosophers point out that issues of forced custody, such as persecution of criminals-mentally retarded and unprotected mothers, and prevention in young people and young people^{8,17,29,30,34}.

Abortion

Abortion with the definitive diagnosis of three physicians and forensic confirmation that fetal disease is caused due to arrhythmia or maladaptation, or maternal morbidity with the life threatening of the mother is permitted before the consent of the woman and punishment and no responsibility is given to the practitioner. Based on this single article and according to the principles of medical ethics, it is for a legal mother to diagnose fetal diseases and abnormalities before and after the onset of the soul (by the end of the 18th week based on LMP and diagnosing the life-threatening diseases of the mother in the event of a pregnancy Before the vomiting of the soul in the fetus, if the mother comes to the doctor^18-20,32,33.

Limit on fertility

Since the parents' duty to create a safe environment for the upbringing of children is an ethical principle, consideration can be given to the physical, mental, economic, and economic strength of couples and the strength of the family institution. Accordingly, it is essential to carefully consider the extent of using these methods to avoid potential future problems and to establish a fit between the wishes of the applicant's couples and the benefits of the newborn baby's expediency. In the following, efforts are made to highlight ethical constraints in providing infertility services to infertility treatment recipients with or without third-party interventions^21-28.

Conclusion: The issue of "reproductive health" in less culture and society is considered an individual and only women's discussion, although its main focus is "women's health." The broader range of medical, ethical, legal, psychological and sociological issues involved in this area involve women, men, children, and a wide range of communities. What is very effective in analyzing related issues and decisions in this area is the cultural-religious context of society. The philosophical foundations of decision making, and the ethical principles and ethics accepted in each community, have an undeniable effect on the general approach of society in the field of reproductive health.

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