As India reports falling fertility rates well below replacement levels in several States, as revealed by the latest National Family Health Survey (NFHS-6), fertility specialists are increasingly calling for infertility treatment to be brought under health insurance coverage.
While declining fertility is often linked to changing social and economic choices, they said a significant number of couples are unable to achieve parenthood despite wanting children due to high costs of diagnosis, investigations and assisted reproductive procedures that have created a major barrier for couples seeking to start or expand their families.
Dr. Archana Dhawan Bajaj, IVF specialist and Founder and Director of The Nurture IVF Centre, Delhi, said the economic realities of infertility treatment are becoming increasingly difficult for many couples.
"Delhi’s fertility rate has fallen to around 1.2, which is significantly below the replacement level. At the same time, infertility treatment remains expensive across the spectrum. Even relatively simple interventions can be costly, while procedures such as IVF are often beyond the reach of many couples," she told The Health Outlook.
According to Dr. Bajaj, infertility treatment differs from many other medical interventions because success is rarely guaranteed in a single attempt.
"The challenge is compounded by the fact that IVF and infertility treatments do not guarantee success in a single attempt. Many couples have to undergo multiple cycles, substantially increasing their financial burden. Unfortunately, most insurance providers in India still do not cover infertility treatment, except for a few limited policies that may support one IVF cycle. As a result, the overwhelming majority of patients are forced to self-fund their treatment," Dr. Bajaj pointed out.
Infertility, defined as the inability to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse, affects millions of couples worldwide. According to the World Health Organisation, nearly one in six adults globally experiences infertility at some point during their reproductive years.
In India, experts say the burden is rising because of delayed marriages, increasing maternal age, sedentary lifestyles, obesity, stress and a growing prevalence of conditions such as PCOS and endometriosis.
"Beyond the financial strain, couples also endure repeated hospital visits, emotional stress, uncertainty, and the psychological impact of treatment failures. In many cases, the prolonged process can even affect relationships between partners. Consequently, for a large number of couples, pursuing treatment repeatedly is simply not a viable option," Dr. Bajaj added.
Dr. Shuchi Rastogi, gynaecologist and infertility specialist and Head of Follicles IVF and Fertility Clinic, echoed similar concerns. "Infertility is an important but often overlooked dimension of reproductive healthcare."
"I believe it is important to recognise that infertility affects couples across socioeconomic groups and carries a significant emotional, social and financial burden. While the economic impact is particularly severe for families with limited resources due to high out-of-pocket expenditure and risk of significant spending, the need for accessible infertility care is universal," said Dr. Rastogi.
She argued that infertility services should become an integral component of reproductive health programmes.
"Integrating rational infertility services into public health programmes and extending appropriate insurance coverage would be a crucial step towards equitable reproductive healthcare," Dr. Rastogi said.
In fact, a multicentric study led by the Indian Council of Medical Research (ICMR) and published in the latest edition of Indian Journal of Medical Research has also provided evidence of the economic burden associated with infertility care, strengthening demands for insurance coverage and greater public-sector support.
Published in the latest issue of the Indian Journal of Medical Research, the study found that infertility treatment in India continues to be financed largely through out-of-pocket expenditure, with nearly six out of ten couples experiencing catastrophic health expenditure while pursuing parenthood.
Led by researchers from the Department of Operational and Implementation Research at the ICMR-National Institute for Research in Reproductive and Child Health (NIRRCH), Mumbai, the study assessed expenditure incurred by couples seeking treatment for conditions such as endometriosis, polycystic ovary syndrome (PCOS), male infertility, uterine disorders and those undergoing intrauterine insemination (IUI).
The researchers found that direct medical expenses constituted the largest component of spending and that costs were substantially higher in private healthcare facilities compared with public institutions. Couples undergoing treatment for endometriosis incurred the highest expenditure, followed by those seeking care for uterine-factor infertility and male infertility.
More significantly, 59.4% of participants reported catastrophic health expenditure, defined as infertility-related spending exceeding 40% of annual household non-food expenditure. The study also found that costs rose considerably among couples without insurance coverage, those with co-existing medical conditions and those undergoing assisted reproductive procedures.
The findings resonate with what fertility specialists say they are witnessing in clinical practice. However, specialists caution that the burden extends beyond finances.
Dr. Ila Gupta, Chairperson and Chief IVF Consultant, Pristyn Care Ferticity, Delhi, said the study reflects realities that fertility specialists encounter daily.
“In my practice, I have been meeting couples very frequently who have spent a significant part of their savings even before reaching a fertility specialist. They move from one consultation to another, undergo repeated investigations, take medications for months, and often travel long distances seeking the right treatment. By the time they begin advanced fertility procedures, many are already under severe financial stress," she said.
Dr. Gupta noted that infertility remains one of the few major medical conditions where treatment expenses are overwhelmingly borne by patients themselves.
Calling for policy intervention, she added that infertility should be treated as a legitimate reproductive health concern rather than a discretionary service.
“Infertility is a reproductive health issue that impacts countless men and women around the world. Therefore access to timely diagnosis and treatment should not be seen as a luxury available only to those who can afford it. There is a growing need to strengthen fertility services within the public healthcare system and explore insurance models that cover at least basic infertility evaluation and treatment. Such measures can help reduce delays in care and will help in improving reproductive outcomes while protecting families from financial hardship.”
As per the NFHS data, fertility rates in Maharashtra, Karnataka and Gujarat have continued to remain below the replacement-level fertility rate of 2.1 children per woman.
The Total Fertility Rate (TFR) stood at 1.8 in Maharashtra, 1.8 in Karnataka and 1.9 in Gujarat in 2023-24, indicating that fertility decline is no longer confined to southern India but is spreading across economically advanced States.
The ICMR-led study involved researchers from PGIMER Chandigarh, Tata Memorial Hospital's National Cancer Grid, Maulana Azad Medical College, Sree Chitra Tirunal Institute for Medical Sciences and Technology, ICMR-NCDIR Bengaluru, Sri Ramachandra Institute of Higher Education and Research, Datta Meghe Institute of Medical Sciences and the Department of Health Research, providing one of the most comprehensive assessments so far of the financial burden associated with infertility care in India.
Health Expenditure While Pursuing Parenthood
Led by researchers from the Department of Operational and Implementation Research at the ICMR-National Institute for Research in Reproductive and Child Health (NIRRCH), Mumbai, the study assessed expenditure incurred by couples seeking treatment for conditions such as endometriosis, polycystic ovary syndrome (PCOS), male infertility, uterine disorders and those undergoing intrauterine insemination (IUI).
The researchers found that direct medical expenses constituted the largest component of spending and that costs were substantially higher in private healthcare facilities compared with public institutions. Couples undergoing treatment for endometriosis incurred the highest expenditure, followed by those seeking care for uterine-factor infertility and male infertility.
More significantly, 59.4% of participants reported catastrophic health expenditure, defined as infertility-related spending exceeding 40% of annual household non-food expenditure. The study also found that costs rose considerably among couples without insurance coverage, those with co-existing medical conditions and those undergoing assisted reproductive procedures.
The findings resonate with what fertility specialists say they are witnessing in clinical practice. However, specialists caution that the burden extends beyond finances.
Dr. Ila Gupta, Chairperson and Chief IVF Consultant, Pristyn Care Ferticity, Delhi, said the study reflects realities that fertility specialists encounter daily.
“In my practice, I have been meeting couples very frequently who have spent a significant part of their savings even before reaching a fertility specialist. They move from one consultation to another, undergo repeated investigations, take medications for months, and often travel long distances seeking the right treatment. By the time they begin advanced fertility procedures, many are already under severe financial stress," she said.
Dr. Gupta noted that infertility remains one of the few major medical conditions where treatment expenses are overwhelmingly borne by patients themselves.
Calling for policy intervention, she added that infertility should be treated as a legitimate reproductive health concern rather than a discretionary service.
“Infertility is a reproductive health issue that impacts countless men and women around the world. Therefore access to timely diagnosis and treatment should not be seen as a luxury available only to those who can afford it. There is a growing need to strengthen fertility services within the public healthcare system and explore insurance models that cover at least basic infertility evaluation and treatment. Such measures can help reduce delays in care and will help in improving reproductive outcomes while protecting families from financial hardship.”
As per the NFHS data, fertility rates in Maharashtra, Karnataka and Gujarat have continued to remain below the replacement-level fertility rate of 2.1 children per woman.
The Total Fertility Rate (TFR) stood at 1.8 in Maharashtra, 1.8 in Karnataka and 1.9 in Gujarat in 2023-24, indicating that fertility decline is no longer confined to southern India but is spreading across economically advanced States.
The ICMR-led study involved researchers from PGIMER Chandigarh, Tata Memorial Hospital's National Cancer Grid, Maulana Azad Medical College, Sree Chitra Tirunal Institute for Medical Sciences and Technology, ICMR-NCDIR Bengaluru, Sri Ramachandra Institute of Higher Education and Research, Datta Meghe Institute of Medical Sciences and the Department of Health Research, providing one of the most comprehensive assessments so far of the financial burden associated with infertility care in India.
