The fertility rate in India has been steadily declining over the past few decades, dropping below the replacement rate of 2.1 children per woman in many states to 1.9, as per the UNFPA’s 2025 State of World Population (SOWP) Report. So are Indian women choosing not to give birth, or are medical complications largely behind what is holding them back?
Dr Hitesha Ramnani, consultant, in-vitro fertilisation (IVF), Kokilaben Dhirubhai Hospital, Mumbai, believes it is a combination of both. “It is a nuanced interplay between choice and circumstance,” she says, adding, “Many urban women are indeed delaying childbirth by choice, prioritising career, financial stability, or personal readiness.”
At a crossroads
Enumerating the health conditions lending to the declining fertility rates in both men and women, Dr Ramnani says, “Polycystic Ovary Syndrome (PCOS), endometriosis, fibroids, thyroid disorders, and male infertility, lifestyle diseases like diabetes, obesity, hypertension are more common in younger age groups today, impacting fertility in both men and women.” She adds that environmental pollution, long working hours, and poor sleep hygiene further add to the issue.
Medical infertility, especially age-related, becomes a bigger barrier after the age of 35, says Dr Ramnani. According to her, women today may be biologically less fertile when they are finally ready to conceive. By this age, issues like diminished ovarian reserve or poor egg quality begin to affect women as well.
Additionally, stress can very significantly impact fertility, she says, expounding that stress itself is a major disruptor of reproductive hormones. “High cortisol levels interfere with ovulation, affect menstrual regularity, and can even reduce the success rates of assisted reproduction,” she explains.
“Chronic stress activates the hypothalamic-pituitary-adrenal (HPA) axis, which suppresses the gonadotropin-releasing hormone (GnRH) pulse generator, leading to menstrual irregularities and anovulation (a condition where the ovaries do not release an egg during the menstrual cycle), thyroid dysfunctions or metabolic syndromes as well,” says Dr Neelam Suri, obstetrician and gynaecologist, Indraprastha Apollo Hospitals, New Delhi.
“A large proportion face involuntary infertility driven by medical causes such as ovulatory disorders, diminished ovarian reserve, tubal blockages, or male factor infertility,” she adds.
Challenges galore
“The average age of conception has increased significantly, particularly in metropolitan areas, where first pregnancies often occur in the early to mid-30s,” observes Dr Suri. Previously, most pregnancies occurred in the early 20s, aligning with peak reproductive potential. The temporal shift is increasing the prevalence of age-related infertility and high-risk pregnancies.
Rising education levels, especially among women, have led to a shift in life priorities, observes Dr Ramnani. Many women are now pursuing higher education and careers, leading to delayed marriages and childbirth. “Moreover, couples today often plan pregnancies more consciously, with better access to contraception and family planning services,” she adds. So, while the decision to delay may stem from choice, the difficulty in conceiving later is often beyond their control, clarifies Dr Ramnani.
Understandably, this has impacted the urban population more keenly, where the decline in fertility rate is far sharper than in rural areas. Nuclear family structures, high living costs, and work-life imbalance have contributed to this phenomenon. Conversely, rural areas still show slightly higher fertility rates, but they, too, are declining due to increased education, awareness, and migration to urban setups, she points out.
Dr Ramnani says, “Working women may delay pregnancy, but non-working women may face pressures of early motherhood. Each demographic carries its own set of challenges.”
Dr Suri, speaking about the reproductive freedom enjoyed by women in the country, opines, “Urban women, especially those pursuing higher education and careers, are more likely to delay conception and present with age-related subfertility or secondary infertility. Women in nuclear families without extended support often defer pregnancy due to logistical constraints. Conversely, rural women are increasingly affected by untreated infections, anaemia, and lack of access to fertility assessments or gynaecological care, which delays timely diagnosis and intervention.”
Work in progress
Speaking from her experience, Dr Suri shares that a large proportion face involuntary infertility. In many cases, reproductive aspirations exist but are compromised by undiagnosed or late-diagnosed gynaecological conditions. According to her, “True reproductive freedom includes access to timely fertility evaluations, assisted reproductive technology (ART), and education about the fertility window, which remains limited in many regions.”
Citing the UNFPA Fertility Report for 2025, Dr Ramnani says that this shows a gap in autonomy over reproductive decisions. “Family pressures, social norms, economic dependency, and lack of proper sexual and reproductive health education contribute to this,” she says. She points out that while urban, educated women may enjoy greater autonomy, many women especially in rural or conservative settings lack the freedom to choose if and when they want to bear children. Not to mention, access to contraception or safe abortion services is also not equitable across the country, she adds, echoing Dr Suri’s views.
Managing issues
Doctors advise that couples should go for comprehensive evaluations including hormonal profiling and pelvic imaging, tubal patency tests and semen analyses as well, after consulting with a fertility specialist.
Depending on the findings, Dr Ramnani says that doctors often suggest treatments like ovulation induction, IUI, or IVF. “For women with diminished ovarian reserve or those choosing to delay pregnancy, egg freezing is a valuable option that offers reproductive flexibility,” she adds.
Dr Suri adds that lifestyle changes can also prove effective from a preventive standpoint. “Maintaining optimal BMI, reducing stress, correcting micronutrient deficiencies (Vitamin D, B12, Iron), regular physical activity, and cessation of smoking/alcohol are crucial lifestyle interventions.”
The solution to this double-edged sword—reproductive freedom to delay conception coupled with the disadvantage of not being able to bear children at the chosen age, among other factors, is systemic, say doctors. “Policymakers must strike a balance: encouraging voluntary, informed family planning while also supporting young families through parental leave, childcare, workplace support for mothers, and fertility education in schools and colleges,” says Dr Ramnani.
Speaking of the issue, Dr Suri opines that the current scenario emphasises the need for reproductive counselling, integration of fertility screening in primary care, and public health initiatives to promote timely parenthood and fertility literacy across socio-economic groups.