One out of 27 children in Japan today are born through in vitro fertilization. More astonishingly, 1 out of 6 couples suffer from infertility. With about 600 fertility clinics and hospitals in operation nationwide, Japan has become known as something of a “superpower of fertility treatment.”
With more and more people starting to have children later in life, an increasing number of couples are turning to medical support to conceive.
What was once an issue that was rarely discussed because of the social stigma attached to it, fertility treatment has become such a common procedure that people are more willing to consider it without hesitation.
However, such treatment isn’t quite as simple as it may first sound. Key procedures are not covered by national health insurance, which pushes up medical costs and adds to the physical and emotional toll endured by couples in the process.
Hibiki Ikeda has been undergoing fertility treatment for 10 years.
When Ikeda first sought professional advice, she was 30 years old and had been trying to conceive for two years. Fertility treatments weren’t openly discussed back then, leaving Ikeda feeling a little isolated when she began visiting an obstetrics and gynecology clinic without telling any of her friends.
“I didn’t want anyone to know that I couldn’t conceive,” Ikeda says. “I was very reluctant to go to a clinic — no one I knew was doing the same thing — but I wanted to know why (I was unable to conceive). It was painful for me to see all of these pregnant women at the clinic. I felt like I was the only one with a flat stomach.”
At present, the Japan Society of Obstetrics and Gynecology says that couples who fail to conceive within two years of having sex without contraception meet its definition of infertility. However, the organization is currently attempting to reduce this term to one year.
Fertility treatment begins with a series of tests conducted at different stages of a woman’s menstruation cycle.
They include various blood tests to check hormone levels, the number of eggs remaining in the ovaries and infectious diseases, as well as a hysterosalpingography to examine the shape of the uterine cavity and the shape and patency of the fallopian tubes. Men are typically asked to undergo semen analysis.
Depending on the test results and age of the woman, patients typically start off by using a calendar rhythm method to determine the best days to have sex. As part of this treatment, women are sometimes given additional hormones a few days before ovulation to ensure that eggs mature. Women who fail to conceive via this method usually then move on to artificial insemination, which is then followed by in vitro fertilization.
Many female patients undergo the same hormone treatment described above to develop the eggs required for in vitro fertilization before they are harvested with a needle, a procedure that is often painful and conducted with the assistance of an intravenous anesthesia.
Ikeda has tried all three treatments, spending about ¥5 million in total on the procedures so far. Although she has managed to conceive three times, she has miscarried twice and given birth to a stillborn baby. She quit her job in order to visit the clinics when required and her marriage was so strained at one point that she even considered divorcing her husband.
“I kept thinking, ‘Why me?'” Ikeda says. “I was forced to accept that there are some things in life that are just beyond your control — no matter how hard you try.”
In vitro fertilization was developed by British physiologist Robert G. Edwards, who was awarded the Nobel Prize in physiology or medicine in 2010. The first successful birth of a baby conceived through in vitro fertilization, Louise Brown, occurred in 1978. It didn’t take Japan long to witness its first birth via in vitro fertilization, with a “test-tube baby” born at Tohoku University in 1983.
Since then, a total of more than 341,750 babies nationwide have been born through in vitro fertilization. In 2012, 326,426 procedures were conducted, which led to the birth of 37,953 babies. This is double the number of babies conceived via this procedure in 2002, when just 15,228 babies were born.
The percentage of babies conceived through in vitro fertilization in the future is going to grow, says Yasunori Yoshimura, a professor emeritus of obstetrics and gynecology at Keio University School of Medicine, noting that fewer babies are being conceived in the country as a whole. Earlier this month, the government announced that the total fertility rate nationwide dropped to 1.42 percent in 2014 — the first decrease in nine years.
In the long term, the government estimates that just 460,000 babies will be born in the year 2055, less than half of the 1 million that were born in 2014.
“The low birthrate will determine whether or not Japan will exist as a country in 50 years time,” Yoshimura says. “Japan will collapse if couples don’t have babies. What’s more, none of the issues Japan currently faces, including infertility, will be resolved unless we create a society in which women can work and raise children.”
Yoshimura says women these days are reluctant to conceive because they continue to receive little support from the government while raising their children. According to the National Institute of Population and Social Security Research, more than 60 percent of women quit their jobs after having their first child, a percentage that has remained unchanged for over 20 years.
“It’s called ‘social infertility,'” Yoshimura says. “Some women who have conceived through in vitro fertilization might not have needed the procedure if they were a few years younger. We are creating an environment where it is becoming harder to get married, conceive and have children. More young people these days are postponing marriage and children.”
Women nationwide are conceiving their first child later and later these days. In 2014, the average age at which a woman had her first child was 30.6. In 1995, it was 27.5.
Yoshimura, the country’s leading expert on fertility treatment, expressed concern over the recent trend. The older you get, he says, the harder it is to conceive.
A woman aged 35 or older experiences more difficulties conceiving than younger women, Yoshimura says. For women aged 35 or older, he says, the possibility of conceiving successfully drops significantly on average. For those aged 40 or older, only 10 percent on average will successfully become pregnant — even through in vitro fertilization. And even if an older woman does conceive successfully, she faces a higher risk of developing high blood pressure or diabetes during pregnancy. Her baby, meanwhile, risks having chromosomal defects such as Down syndrome.
“There is a lack of education on pregnancy,” Yoshimura says. “People think they can get pregnant whenever they want. So when the media plays up a famous personality’s pregnancy when she is in her 40s, people think it will also happen to them.”
It’s not hard to see some truth in his observations. Award-winning author Mariko Hayashi, former professional wrestler Jaguar Yokota and actress Misako Tanaka all had their first child in their early- to mid-40s, while Liberal Democratic Party lawmaker Seiko Noda and radio personality Miki Sakajo conceived in their early 50s. Noda’s 4-year-old son is severely disabled, and has undergone 11 surgeries in his life so far.
Nevertheless, Yoshimura says that such cases are still extremely rare.
“It’s a little strange,” Yoshimura says. “When people are told they have a 10 percent chance of developing breast cancer, they assume the worst. When it comes to pregnancy, however, people somehow believe it will work in their favor.”
Lack of legislation
There is currently no law regulating reproductive technology, just guidelines — principally issued by the Japan Society of Obstetrics and Gynecology — on controversial topics such as oocyte cryopreservation (egg freezing) for women with health issues, semen cryopreservation (sperm banking), surrogate pregnancy, artificial insemination by donors and prenatal screening tests. If a clinic ignores such guidelines, it faces being kicked out of the organization.
The LDP has every once and a while attempted to draft legislation on reproductive technology, only to give up after failing to reach a consensus among party members.
The party is currently in the middle of discussing a number of related controversial issues, including whether to formalize laws regulating surrogacy and sperm or egg donations by a third person. Some women are traveling abroad for such procedures as the legislation surrounding them remains vague.
Azumi Tsuge, professor of sociology at Meiji Gakuin University and an expert in fertility issues, says more support needs to be given to children who are conceived through such treatments.
“Whether the procedures are legal or illegal is not important,” Tsuge says. “What does matter, however, is the support given to children who are born through surrogacy or as a result of donated sperm or eggs. Some might not be interested in their lineage but others could be. And when they learn the truth, they may need a lot of support because it could come as a great shock.”
Tsuge has been researching the experiences of women who undergo fertility treatment since the early 1990s. She recalls being surprised by the number of women who were undergoing treatment in secret. She was also shocked to see how emotionally and physically drained they were.
“People don’t know how difficult fertility treatment is,” Tsuge says. “They should be warned about how tough things will get before starting such procedures.”
Tsuge says many people she interviewed have highlighted the importance of blood ties, which may be related to the country’s prewar family registration system.
In this system, power was centralized to the head of a household, who was, in principle, the first son. Families without sons often adopted boys.
“Since the postwar economic growth period, people have become more interested in blood relations, not generational families,” Tsuge says. “I think the concept of DNA is mixed with the country’s ideology behind the registration system.”
Knowing when to stop
A total of 466,900 people sought fertility treatment in 2003 — the last time the government compiled statistics on the procedure. It is highly likely the number of people seeking such treatment has increased significantly since then.
The outlay for fertility treatment isn’t cheap. The initial procedures, including ovulation induction, are covered by national health insurance, but artificial insemination and in vitro fertilization are not. Prices for artificial insemination range from about ¥10,000 to ¥30,000 per treatment, while in vitro fertilization costs about ¥300,000 to ¥500,000. Given that many women go through multiple procedures, the money adds up quickly. And once couples start down this road, it’s difficult to decide when to quit.
“Fertility clinics are making lots of money,” Tsuge says. “Are those procedures really all necessary? Fertility treatment is emotionally and physically draining, and therefore it is important to decide when to stop before starting.”
The government offers subsidies for in vitro fertilization to married couples with an income of less than ¥7.3 million annually. Currently, there is no age limit and ¥150,000 will be given per in vitro procedure up to 10 times over a period of five years. Couples can apply up to three times in the first year and twice annually from the second year.
Starting April 2016, the subsidies will only be given to couples whose wives are younger than 43 years old. Those younger than 40 will be able to apply six times, while those who are 40, 41 and 42 will be able to apply three times. The current amount, in general, is ¥150,000 per attempt, while some local governments also offer additional subsidies.
According to a 2013 survey compiled by the nonprofit organization Fine, a self-support group for women who have or are undergoing fertility treatment, women are still paying a lot of money to conceive. Out of roughly 2,000 respondents, more than half had paid more than ¥1 million.
Akiko Matsumoto, co-founder of Fine, says many women don’t realize that the older you get, the more difficult it is to conceive. They ultimately end up seeking professional advice, which ends up costing a lot of money and taking up a lot of time.
“These procedures are very expensive — some cost ¥1 million for just one treatment,” Matsumoto says. “These couples can’t afford it unless both of them are working but many women find it difficult to do both and are caught in the middle.”
Ikeda was forced to make that decision at 35. She was working at a publishing agency but frequently had to take time off at odd hours or suddenly take a day off in order to visit a clinic. She hadn’t told anyone at her office about her treatments and knew she could no longer continue.
Her life changed completely after joining Fine and befriending others who had gone through such therapy. Now, at 40, she is a counselor for people who are going through the same process. She is giving herself one last year of treatment before quitting completely. She and her husband are now looking into adoption.
“I’ve come to realize my value as a woman does not depend on being able to conceive,” Ikeda says. “I now know that there are other joys in life and not being able to conceive does not make my life any less fortunate.”