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On Oct. 24, TV personality Dewi Sukarno claimed on the Kansai TV talk show “Mune Ippai Summit!” that the main cause of infertility in Japan was abortion. The topic under discussion was the proposal by the administration of Prime Minister Yoshihide Suga to allow national insurance coverage for fertility treatments, and Sukarno, who thinks abortion should be banned, claimed that the most common procedure in Japan, dilation and curettage, damages the uterus, thus making it impossible for the patient to ever have babies again.

Both Kansai TV and Sukarno subsequently apologized for the remark, which was criticized for being false and inappropriate. However, it’s difficult to gauge how much her opinion reflected that of the public, or how many people who heard the comment believed it and disregarded the subsequent retraction.

The distinction is important since abortion is a taboo subject, as it is in many places in the world, so it’s easy to spread false information, especially in Japan where related statistics are unreliable. Technically, abortion in Japan is only legal under special circumstances, including economic hardship. Whether gynecologists screen for these circumstances isn’t clear because, as most abortions are not covered by national health insurance, record-keeping is dodgy. The health ministry reported about 168,000 abortions in 2016, although the number may be higher.

Fertility treatments, whether for men or women, are also not covered by insurance because in most cases infertility is not defined as an ailment. In principle, national health insurance is only used to treat illness or injury. It doesn’t cover checkups and preventive care. But now the government has come around to the notion that infertility may mean there’s something wrong, and so treatment can be covered by insurance. Although the public seems to be in favor, doctors are pushing back, since they won’t make as much money. Gynecologists charge whatever they want for abortions and fertility treatments. The irony is that women who use the economic option to justify their need for an abortion are implicitly too poor to afford one, but they have to pay full price out of their own pockets.

Last year, NHK’s “Heart Net TV” program aired a rare conversation between two gynecologists — one female, the other male — about abortion. The male gynecologist, Ko Sakuma, says he performs more than 1,000 a year and admits that it’s like an assembly line. The female gynecologist, Sakiko Enmi, is studying abortion as a rights issue, and thinks that, despite the high number of procedures performed here, Japan is behind the rest of the developed world in terms of women’s reproductive health. For one thing, the preferred dilation and curettage method goes against global trends. She also thinks that Japan’s strict regulations on the so-called morning-after pill are problematic, given how it is available over the counter in many countries.

Sakuma uses the dilation and curettage method, and thinks the possibility of side effects justifies the government’s stance on the morning-after pill, which still requires a prescription in Japan. Significantly, he says if the pill were mainstreamed, gynecologists would lose business. When Enmi notes that abortions cost more than ¥100,000, Sakuma says it’s because doctors know they can make money. Enmi calls this burden a kind of “punishment” for women.

So the market offers more to gynecologists, regardless of whether they perform abortions or provide fertility treatments. An Oct. 22 article in Diamond Online that discussed the government proposal described Japan as a “fertility treatment paradise,” since it records more births as a result of in vitro fertilization than any other country in the world — 56,979 in 2018, out of a total 918,400 births.

Diamond wonders if allowing public funds to pay for fertility treatment benefits society as a whole. In 2018, about 450,000 fertility treatments were carried out. Had insurance paid for these treatments it would have cost the government between ¥100 billion and ¥150 billion. At present, couples can receive up to ¥300,000 from the government to pay for first-time treatment, depending on the couple’s income, and they can also deduct those fees on their income tax returns.

A recent piece by Masahiro Kami, head of the Medical Governance Research Institute, on the Japan In-depth website explains that gynecologists who provide fertility treatment would see their incomes drop if insurance coverage is allowed. Since the government must approve all medications and treatments covered by insurance, doctors might have to change their preferred methods. When an unapproved drug is part of the method, the whole treatment is disallowed for insurance purposes, and doctors would not have as much flexibility in determining a treatment course. Kami predicts that more infertility clinics would go out of business as a result, and even those which survive would labor under a uniform pricing system, which means they would need more patients to make as much money as they do now and, as a result, the quality of treatment would suffer.

All these supposed drawbacks are based on what doctors think they should make. The national insurance system also takes into consideration what the public and the government can afford. An Asahi Shimbun forum on the insurance scheme quoted a man in his 20s who said he and his wife spent 3½ years and ¥2.6 million to produce their first child and, if insurance is allowed, they might try for a second one. That’s the kind of response the government wants to hear, but most people who undergo fertility treatment are older.

A woman in her 40s quoted in the forum said that if insurance is allowed, there should be age limits and, if the cost goes down, “some people may not know when to give up.” After all, success is not guaranteed, and the possibility of success drops with age. Cost effectiveness isn’t the avowed priority of the government, but encouraging more fertility treatments may not have a dramatic effect on the birthrate anyway. Keeping the cost of abortions high will not discourage women from seeking them, and reducing the cost of fertility treatment won’t necessarily mean more Japanese children.

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