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.

The world is ill-prepared for the global crash in children being born which is set to have a "jaw-dropping" impact on societies, say researchers.

Falling fertility rates mean nearly every country could have shrinking populations by the end of the century.

And 23 nations - including Spain and Japan - are expected to see their populations halve by 2100.

Countries will also age dramatically, with as many people turning 80 as there are being born.

What is going on?

The fertility rate - the average number of children a woman gives birth to - is falling.

If the number falls below approximately 2.1, then the size of the population starts to fall.

In 1950, women were having an average of 4.7 children in their lifetime.

Researchers at the University of Washington's Institute for Health Metrics and Evaluation showed the global fertility rate nearly halved to 2.4 in 2017 - and their study, published in the Lancet, projects it will fall below 1.7 by 2100.

As a result, the researchers expect the number of people on the planet to peak at 9.7 billion around 2064, before falling down to 8.8 billion by the end of the century.

"That's a pretty big thing; most of the world is transitioning into natural population decline," researcher Prof Christopher Murray told the BBC.

"I think it's incredibly hard to think this through and recognise how big a thing this is; it's extraordinary, we'll have to reorganise societies."

Why are fertility rates falling?

It has nothing to do with sperm counts or the usual things that come to mind when discussing fertility.

Instead it is being driven by more women in education and work, as well as greater access to contraception, leading to women choosing to have fewer children.

In many ways, falling fertility rates are a success story.

Which countries will be most affected?

Japan's population is projected to fall from a peak of 128 million in 2017 to less than 53 million by the end of the century.

Italy is expected to see an equally dramatic population crash from 61 million to 28 million over the same timeframe.

They are two of 23 countries - which also include Spain, Portugal, Thailand and South Korea - expected to see their population more than halve.

"That is jaw-dropping," Prof Christopher Murray told me.

China, currently the most populous nation in the world, is expected to peak at 1.4 billion in four years' time before nearly halving to 732 million by 2100. India will take its place.

The UK is predicted to peak at 75 million in 2063, and fall to 71 million by 2100.

However, this will be a truly global issue, with 183 out of 195 countries having a fertility rate below the replacement level.

Why is this a problem?

You might think this is great for the environment. A smaller population would reduce carbon emissions as well as deforestation for farmland.

"That would be true except for the inverted age structure (more old people than young people) and all the uniformly negative consequences of an inverted age structure," says Prof Murray.

The study projects:

• The number of under-fives will fall from 681 million in 2017 to 401 million in 2100.
• The number of over 80-year-olds will soar from 141 million in 2017 to 866 million in 2100.

Prof Murray adds: "It will create enormous social change. It makes me worried because I have an eight-year-old daughter and I wonder what the world will be like."

Who pays tax in a massively aged world? Who pays for healthcare for the elderly? Who looks after the elderly? Will people still be able to retire from work?

"We need a soft landing," argues Prof Murray.

Are there any solutions?

Countries, including the UK, have used migration to boost their population and compensate for falling fertility rates.

However, this stops being the answer once nearly every country's population is shrinking.

"We will go from the period where it's a choice to open borders, or not, to frank competition for migrants, as there won't be enough," argues Prof Murray.

Some countries have tried policies such as enhanced maternity and paternity leave, free childcare, financial incentives and extra employment rights, but there is no clear answer.

Sweden has dragged its fertility rate up from 1.7 to 1.9, but other countries that have put significant effort into tackling the "baby bust" have struggled. Singapore still has a fertility rate of around 1.3.

Prof Murray says: "I find people laugh it off; they can't imagine it could be true, they think women will just decide to have more kids.

"If you can't [find a solution] then eventually the species disappears, but that's a few centuries away."

The researchers warn against undoing the progress on women's education and access to contraception.

Prof Stein Emil Vollset said: "Responding to population decline is likely to become an overriding policy concern in many nations, but must not compromise efforts to enhance women's reproductive health or progress on women's rights."

What about Africa?

The population of sub-Saharan Africa is expected to treble in size to more than three billion people by 2100.

And the study says Nigeria will become the world's second biggest country, with a population of 791 million.

Prof Murray says: "We will have many more people of African descent in many more countries as we go through this.

"Global recognition of the challenges around racism are going to be all the more critical if there are large numbers of people of African descent in many countries."

Why is 2.1 the fertility rate threshold?

You might think the number should be 2.0 - two parents have two children, so the population stays the same size.

But even with the best healthcare, not all children survive to adulthood. Also, babies are ever so slightly more likely to be male. It means the replacement figure is 2.1 in developed countries.

Nations with higher childhood mortality also need a higher fertility rate.

What do the experts say?

Prof Ibrahim Abubakar, University College London (UCL), said: "If these predictions are even half accurate, migration will become a necessity for all nations and not an option.

"To be successful we need a fundamental rethink of global politics.

"The distribution of working-age populations will be crucial to whether humanity prospers or withers."