Decisive factors in medical tourism destination choice: a case study of isfahan, iran and fertility treatments
Decisive factors in medical tourism destination choice: A case studyof Isfahan, Iran and fertility treatments
Farhad Moghimehfar ,, Mohammad Hossein Nasr-Esfahani
a Department of Tourism Management, Allameh Tabataba’i University, Nezami Ganjavi St., Tavanir St. Tehran, Iran
b Isfahan Fertility and Infertility Center, Isfahan, Iranc Royan Institute of Animal Biotechnology, ACECR, Isfahan, Iran
The birth of the ﬁrst in vitro fertilized baby, followed by further advances in the ﬁeld of assisted
reproductive technology (ART) has made this technology one of the most attractive tourism innovations
among the different categories of medical tourism. In addition, factors such as legal, moral, religious andethical issues play important roles in choosing reproductive tourism destinations. The aim of this study
was to examine the factors inﬂuencing destination choice in infertile couples who referred to the Isfahan
Fertility and Infertility Center in Isfahan, Iran. Field evaluation was carried out based on a documentary
survey and questionnaire completed by interviewers. Among a target group of 80 infertile couples, 67
were interviewed. The majority of participants in this study were Muslim couples who traveled for
reproductive tourism to Iran. It can be concluded that religious afﬁnity may have paramount importancein reproductive medical tourism for Muslim infertile couples.
Ó 2011 Elsevier Ltd. All rights reserved.
The growth of medical tourism, and the role of fertility treat-
Many hospitals and fertility clinics in the Middle East provide
ments within this form of tourism have attracted academic studies
infertility treatment through ART ). More than 70
to explore its effects and improve future planning. According to
clinics and specialized medical centers in Iran offer infertility
treatment to both Iranian and non-Iranian couples.
5e30% of the world’s population have been affected by primary and
Iran, located in the Middle East, is surrounded by Muslim coun-
secondary infertility. As a result of recent advances in the ﬁeld of
tries such as Iraq, Afghanistan, Pakistan, Turkey, and Azerbaijan, to
assisted reproductive technology (ART), followed by a rise in the
name a few. The majority of Iran’s population is Muslim of the Shi’a
population of medical tourists, the number of infertile couples who
sect. Many natural tourist attractions, historical and archeological
seek international fertility facilities has increased as well. Nowa-
sites with more than 7000 years of urban settlements, in addition to
days, many countries worldwide offer a vast range of medical
famous cities that have rich Islamic and pre-Islamic cultural back-
services which differ in quality and cost ). Thus
grounds such as Isfahan, Shiraz and Yazd are located in Iran
infertile couples have choices of medical tourism destinations from
). Moreover, many sacred places for Shi’a Muslims termed
among these countries. Many factors may inﬂuence the destination
“Imam Zadeh” are located throughout Iran
choice among this category of tourists. The main objectives of this
study are to identify the demographic proﬁles of non-Iranian
Isfahan, one of the largest cities in Iran, is located in a central
infertile couples who have referred to the Isfahan Fertility and
part of the country with numerous historical sites and heritages
Infertility Center in Iran and investigate factors which affect
that are mostly from the Islamic period (). A vast
destination choices among this group of tourists.
range of tourism facilities and hospitable nature encourages manydomestic and international tourists to visit Isfahan. Isfahan alsoprovides medical facilities such as general hospitals and specialty
* Corresponding author. Tel.: þ98 9139064462; fax: þ98 3112600446.
medical centers. Isfahan Fertility and Infertility Center is a non-
governmental fertility clinic which provides reproductive services
1 Tel.: þ98 9131199888; fax: þ98 3112600446.
to both Iranian and non-Iranian couples.
0261-5177/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
F. Moghimehfar, M.H. Nasr-Esfahani / Tourism Management 32 (2011) 1431e1434
interpreters). Seventy infertile couples (among 80 infertile touristswho referred to the center during the study period) were inter-
Numerous studies in the ﬁeld of decisive factors on the choice of
viewed and 67 usable questionnaires were analyzed. Both the
destination for medical tourism have been carried out recently
documentary survey and interviews were carried out anonymously
and an informed consent form was obtained from all volunteer
research pertains to numerous types of illnesses while others are
participants. The study was carried out during a six month period
more focused and study particular illnesses and conditions.
from September 2009 to March 2010. Collected data were analyzed
Many studies in the ﬁeld of medical tourism show cost beneﬁt to
using descriptive statistics and the chi-square test, with SPSS 16.0
be one of the initial factors which encourages medical tourists to
The distance betweenthe patients’ country of origin and their medical destination affects
both their transportation cost and convenience ().
While visiting the destination country, many medical tourists try to
The ﬁrst section of the questionnaire was designed to obtain
ﬁnd a popular tourism country in which they could enjoy their trip
demographic information about the respondents. As shown in
according to religion, it was noted that all respondents were
All the above-mentioned factors were pull factors which create
Muslim couples, of which 64.2% were Iraqi, 17.9% Afghan, 7.5%
demand, while certain push factors in the traveler generating
Pakistani and 10.4% were infertile couples from other countries. The
region seem to be important as an origin of tourism demand
majority were Shi’a (94%) and the remainder (6%) Sunni Muslims
). The lack of advanced medical technology or
(three Pakistani and one Iraqi couple). A total of 82.1% of these
expertise, and quality of services are some of the push factors
couples entered Iran by land while the remaining 17.9% traveled by
air. Only 6% of these couples encountered problems during their
). In many countries worldwide ART, mainly
applications for a visa. Of couples, 71.6% rented houses during their
those related to donation or surrogate motherhood are illegal
treatment period, 16.4% of them stayed at hotels and the remaining
11.9% stayed with their Iranian resident friends or relatives. In
addition, most Afghan couples mentioned that they were previ-
ously in Iran as social workers (11 out of 12). Finally, 32.8% of males
moral (or religious ethical issues ).
and 49.2% of females had a high school diploma or below, whereas
Some studies have found the term “reproductive exile” more
67.2% of males and 50.8% of females were university graduates.
accurate than “reproductive tourism” In addition to these legal restrictions, in some
cases, barriers are due to the infertile couple’s religious beliefs.
Sunni and Shi’a are two branches in Islam. The majority of
shows the frequency of answers to each question and
Muslims (80e90%) are Sunni. Shi’a, another branch of Islam, is
mostly located in Iran, Iraq, Lebanon, Bahrain, Syria, Saudi Arabia,
An open ended question was added to statement number ﬁve
Afghanistan, Pakistan and India (The Shi’a and Sunni
“Which kind of attractions in Iran do you like the most?” Of
branches have different rules (orders) concerning ART. In Shi’a,
respondents, 68.6% asserted that they were highly interested in
surrogate motherhood is allowed as well as egg donation under
pilgrimage; the majority mentioned Mashhad (the most religiously
certain circumstances (In the Sunni branch however,
important city in Iran, particularly for Shi’a Muslims). The other
all forms of third party donor, including surrogacy are forbidden
8.9% were interested in visiting historical sites in Isfahan and Shiraz,
(). Fertility through ART in a religiously correct
and the remainder (22.5%) did not answer this question.
fashion seems to be very important to many Muslim infertile
Based on the results gained from chi-square analysis (all
couples ). It is proposed that a study of this minority
signiﬁcant at the level of 0.01) and frequency of responses, it was
group of reproductive tourists helps to plan for future medical
determined that the infertile couples who participated in this study
agreed about that all the above factors had an inﬂuence on theirdecision making.
A documentary survey and questionnaire were the major
research techniques used in this study. At ﬁrst, a documentarysurvey was carried out on the medical records of non-Iranian
infertile couples who referred to the Isfahan Fertility and Infertility
Center during the last ﬁve years. Then, a questionnaire that con-
sisted of eight simple questions was designed to ﬁnd reproductive
tourists’ attitudes toward factors that affected their destination
choice of infertility treatment services. The questionnaire was
measured by the ﬁve point Likert Scale which ranged from
“strongly agree” to “strongly disagree”. Its validity was conﬁrmed
by university faculty professors and a literature review, and the
reliability coefﬁcient was conﬁrmed by Cronbach alpha (0.725)
after a pilot test. The Persian questionnaire was then translated into
English and Arabic, as all respondents could speak and understand
either of these three languages. The main data was gathered by
F. Moghimehfar, M.H. Nasr-Esfahani / Tourism Management 32 (2011) 1431e1434
Table 2Level of respondents’ agreement with each statement and chi-square analysis results.
1. My destination choice was affected by the distance between my
2. My destination choice was affected by the low price of infertility
3. My destination choice was affected by lack of expertise or ART
4. My destination choice was affected by legal or moral restrictions
5. My destination choice was affected by tourist attractions of Iran.
6. Receiving reproductive medical services in the religiously correct
7. Implementation of ART in the religiously correct fashion in Iran is
8. Level of agreement with traveling to a non-Muslim country to receive
a Question: Please specify your level of agreement with each statement by checking the appropriate response.
b SD ¼ Strongly disagree, MD ¼ Moderately disagree, N ¼ Not agree nor disagree, MA ¼ Moderately agree, SA ¼ Strongly agree.
The results in show that some factors seem to be more
important for Muslim infertile couples participating in this study inthe choice of their medical treatment destination. It can be inferred
The authors wish to thank Ekhlas Ghotbi (Arabic interpreter),
from the frequencies of the responses that religious ethical issues
Mehrnoush Motiee, Zohre Shamandi MD., and Mehran Rajaian, for
statement nos. 6, 7 and 8) and legal or moral restrictions in
their kind helps. We also thank Professor Dr. Marcia C. Inhorn, for
their home country statement no. 4) rank among the most
important factors in their choice of a destination country to receiveinfertility treatment services.
Lack of expertise or ART is another factor which inﬂuenced their
choice. Demographic statistics in indicate that the majorityof these infertile couples are Iraqi and Afghan (82.1%) of which most
Supplementary material related to this article can be found at
do not have access to high quality medical facilities or expertise in
their own countries. In addition, Afghan people preferred to travelto Iran for their treatment because most have been working in this
country as social immigrant workers for a period of time.
Blyth, E., & Farrand, A. (2005). Reproductive tourism e a price worth paying for
reproductive autonomy? Critical Social Policy, 25(1), 91e114. doi:10.1177/
Burkett, L. (2007). Medical tourism concerns, beneﬁts, and the American legal
The present study aimed to investigate the impact of factors
perspective. The Journal of Legal Medicine, 28, 223e245.
such as cost, distance, lack of expertise, tourist attractions, legal and
Christine, L. (2007). Just what the doctor ordered. Monash Business Review, 3(3),
moral restrictions, and religious ethical issues upon infertile
Connell, J. (2006). Medical tourism: sea, sun, sand and . surgery. Tourism
couples’ destination choices for treatment with ART. The research
Management, 27(6), 1093e1100. doi:10.1016/j.tourman.2005.11.005.
results indicated that in addition to some general factors which
Derckx, V. (2006). Expulsion of illegal residents (aliens) with medical problems and
article 3 of the European convention on human rights. European Journal of
motivate all groups of international medical tourists (price,
distance, lack of expertise, tourist attractions), there are additional
Heng, B. C. (2006). ‘Reproductive tourism’: should locally registered fertility doctors
important factors which speciﬁcally inﬂuence infertile couples’
be held accountable for channeling patients to foreign medical establishments?Human Reproduction, 21(3), 840e842. doi:10.1093/humrep/dei402.
destination choices for infertility treatment or require that they
Heng, B. C. (2007). Taiwan (Republic of China) legitimizes substantial ﬁnancial
travel to a qualiﬁed country to receive reproductive medical
remuneration of egg donors: implications for reproductive tourism in East Asia.
Expert Review of Obstetrics & Gynecology, 2(5), 545e547. doi:10.1586/17474184.108.40.2065.
The ﬁndings of this study and some previous studies have
Hooshangi, F. (2000). Isfahan, city of paradise: A study of Safavid urban pattern and
suggested that legal and moral issues prevent infertile couples from
a symbolic interpretation of the Chahar-Bagh gardens. (Master’s thesis). Retrieved
receiving ART beneﬁts in their country of residence.
from ProQuest Dissertations and Theses Database. (AAT MQ52378).
Howze, K. S. (2007). Medical tourism: symptom or cure? Georgia Law Review, 41(3),
This research emphasizes the importance of ART in a religiously
correct fashion as a very important factor for Shi’a Muslims as seen
Inhorn, M. C. (2003). Global infertility and the globalization of new reproductive
technologies: illustrations from Egypt. Social Science and Medicine, 56(9),
Inhorn, M. C. (2005). Fatwas and ARTs: IVF and gamete donation in Sunni v. Shi’a
couples’ religious beliefs are respected and considered during the
Islam. (Assisted reproductive technologies, in vitro fertilization). Journal of
treatment of infertility through ART will make reproductive
Gender, Race and Justice, 9, 291e317.
tourism a remarkable opportunity for these minority groups who
Inhorn, M. C. (2006). Making Muslim babies: IVF and gamete donation in Sunni
versus Shi’a Islam. Culture, Medicine and Psychiatry, 30(4), 427e450.
are faced with a lack of ART expertise in their country of
Inhorn, M. C., & Fakih, M. H. (2006). Arab Americans, African Americans, and
Eventually, despite remarkable recent advances in ART, global-
infertility: barriers to reproduction and medical care. Fertility and Sterility, 85(4),844e852. doi:10.1016/j.fertnstert.2005.10.029.
ization of this technology will not occur unless a combination of
Inhorn, M. C., & Patrizio, P. (2009). Rethinking reproductive “tourism” as repro-
moral, legal and religious ethical issues are carefully considered.
ductive “exile”. Fertility and Sterility, 92(3), 904e906.
F. Moghimehfar, M.H. Nasr-Esfahani / Tourism Management 32 (2011) 1431e1434
Jones, C. A., & Keith, L. G. (2006). Medical tourism and reproductive outsourcing: the
Shenﬁeld, F., de Mouzon, J., Pennings, G., Ferraretti, A. P., Nyboe Andersen, A., de
downing of a new paradigm for health care. International Journal of Fertility and
Wert, G., et al. (2010). Cross border reproductive care in six European
Matorras, R. (2005, December). Reproductive exile versus reproductive tourism
[Letter to the editor]. Human Reproduction, 20(12), 3571e3573. doi:10.1093/
Sills, E. S., Qublan, H. S., Blumenfeld, Z., Dizaj, A. V., Revel, A., Coskun, S., et al. (2007).
Regional clinical practice patterns in reproductive endocrinology: a collabora-
Ministry of Culture and Islamic Guidance. (2003). Comprehensive cultural statistics:
tive transnational pilot survey of in vitro fertilization programs in the Middle
Iran cultural sites, list of shrines and sacred places. Tehran: National Plan,
East. Journal of Experimental & Clinical Assisted Reproduction, 3(4). doi:10.1186/
Ministry of Culture And Islamic Guidance.
Nachtigall, R. D. (2006). International disparities in access to infertility services.
Tosun, C., & Jenkins, C. L. (1998). The evolution of tourism planning in third-
Fertility and Sterility, 85(4), 871e875. doi:10.1016/j.fertnstert.2005.08.066.
world countries: a critique. Progress in Tourism and Hospitality Research, 4(2),
Pennings, G. (2002). Reproductive tourism as moral pluralism in motion. Journal of
Medical Ethics, 28, 337e341. doi:10.1136/jme.28.6.337.
Turner, L. (2007). ‘First world health care at third world prices’: globalization,
Pennings, G. (2004). Legal harmonization and reproductive tourism in Europe.
Human Reproduction, 19(12), 2689e2694. doi:10.1093/humrep/deh486.
Pennings, G., Autin, C., Decleer, W., Delbaere, A., Delbeke, L., Delvigne, A., et al.
(2009). Cross-border reproductive care in Belgium. Human Reproduction, 24(12),
H. K. Heggenhougen, & S. Quah (Eds.), International encyclopedia of public health,
Vol. 3 (pp. 576e587). San Diego, CA: Academic Press.
Ramírez de Arellano, A. B. (2007). Patients without borders: the emergence of
Zendeh Del, H. (2001). Iran travel guide, cities and provinces. Tehran: Karevane
medical tourism. International Journal of Health Services, 37(1), 193e198.
Mental Health America of Franklin County 2323 W. Fifth Ave. Suite 160, Columbus, OH 43204 Telephone: (614) 221-1441 Fax: (614) 221-1491 Medications/Treatments: General Guidelines A Guide For Families, Friends, Board And Care Homes, Caregivers And Patients Prescription medications are helpful in reducing symptoms in people suffering with a mental illness. As with any medi
GRIPPE A /H1N1 ASMT TARBES 2009 GENERALITE La grippe est une infection respiratoire aiguë très contagieuse , les virus grippaux se répartissent entre différents types : A ,B ,C ; Seul le virus A est responsable de pandémie. Définition d'une pandémie: Forte augmentation de cas d'une même maladie à un moment donné, dans une zone géographique très étendue. L