How air pollution, stress and late pregnancies are fuelling India’s fertility crisis – Firstpost

Infertility is emerging as a pressing public health concern in India, affecting an estimated 10–15% of couples according to studies published in The Lancet and other medical journals. The issue has been further spotlighted by government data and clinical observations pointing to a surge in conditions like PCOS, endometriosis and declining sperm quality, particularly in urban centres.

Environmental stressors such as air pollution and exposure to endocrine-disrupting chemicals, combined with sedentary lifestyles and delayed family planning, are compounding the crisis. The Indian Council of Medical Research and the Ministry of Health have taken regulatory steps with the Assisted Reproductive Technology (Regulation) Act to ensure standardised fertility care but challenges around accessibility, affordability and awareness persist—especially in tier-2 and tier-3 cities.

Firstpost talked to Dr. Mannan Gupta, Chairman & HOD, Obstetrics & Gynaecology & IVF, Elantis Healthcare (New Delhi) to understand the underlying medical and environmental factors behind India’s infertility burden, how air pollution and lifestyle are affecting IVF outcomes, and the current state of ART practices across the country.

What are the main medical and environmental factors behind the rising burden of infertility in India?

Dr Mannan: Infertility now affects nearly 10–15% of couples in India, and the trend is steadily increasing. Medically, rising cases of Polycystic Ovary Syndrome (PCOS), endometriosis, thyroid disorders, diabetes, and obesity in women are significant contributors. In men, conditions like varicocele, hormonal imbalances, and poor sperm parameters are commonly seen. Environmentally, increasing exposure to endocrine-disrupting chemicals (EDCs), air pollution, and unhealthy lifestyle habits—such as poor diet, lack of exercise, smoking, alcohol consumption, and chronic stress—are worsening reproductive health. Additionally, delayed marriages and late pregnancy planning have become major socio-cultural factors contributing to declining fertility.

How are declining sperm quality and ovarian reserve due to air pollution and sedentary lifestyles impacting IVF outcomes, especially in urban India?

Dr Mannan: In urban settings, declining sperm counts and ovarian reserves have become major challenges for successful conception—both naturally and via assisted reproduction. Studies show increasing DNA fragmentation in sperm and diminished anti-Müllerian hormone (AMH) levels in women exposed to high-pollution environments. These directly reduce embryo quality and negatively impact IVF success rates. Sedentary habits, obesity, and poor sleep hygiene further impair hormonal health. As a result, we often require multiple IVF cycles and personalised stimulation protocols to achieve a viable pregnancy, especially in metropolitan cities.

How accessible and affordable is IVF treatment across India, particularly in tier-2 and tier-3 cities?

Dr Mannan: While IVF is gaining popularity and acceptance, affordability and access remain significant hurdles outside metro cities. In tier-2 and tier-3 areas, there is limited availability of advanced infrastructure, skilled embryologists, and fertility specialists. Many couples are forced to travel to metro cities, which increases emotional and financial burdens. Moreover, infertility is still considered taboo in several regions, leading to delayed medical intervention. Although some states are considering subsidised treatment or insurance coverage for infertility, there is still a long way to go in terms of accessibility and affordability at the national level.

What realistic expectations should couples, especially those over 35, have when starting IVF?

Dr Mannan: IVF success rates typically range from 30% to 50%, depending on factors like the woman’s age, the cause of infertility, and the clinic’s expertise. For women above 35, success rates start to decline due to reduced ovarian reserve and egg quality. It is crucial for couples to understand that IVF is not a guarantee of pregnancy in the first cycle. It may require two or more attempts, and in some cases, advanced techniques like donor eggs or preimplantation genetic testing (PGT) may be recommended. Emotional and psychological support also plays a big role during this journey.

Since the implementation of ICMR guidelines and ART legislation, how have clinical practices, patient safety, and ethical standards changed?

Dr Mannan: The Assisted Reproductive Technology (Regulation) Act and ICMR guidelines have brought much-needed standardisation to IVF practices across India. Clinics now require mandatory registration, ensuring quality control and accountability. There are clear protocols for consent, gamete donation, surrogacy, and embryo storage. This has significantly improved patient safety, reduced unethical practices, and built greater transparency in treatment. While compliance can sometimes increase operational costs, it ultimately enhances trust between patients and healthcare providers.

Are clinics in India adopting single embryo transfer more frequently to minimise complications from multiple pregnancies?

Dr Mannan: Yes, there is a growing shift towards single embryo transfer (SET), especially in younger women with good-quality embryos. While earlier practices often involved transferring two or more embryos to boost chances, we now understand that multiple pregnancies increase maternal risks such as hypertension, preterm birth, and NICU admissions. With improved embryo culture systems, blastocyst transfers, and technologies like vitrification (rapid freezing), SET has become a safe and effective option. However, adoption still varies across clinics and regions based on patient preference, cost considerations, and expectations.

What does current evidence suggest about egg freezing and fertility preservation in working women and cancer patients?

Dr Mannan: Egg freezing has emerged as a valuable tool for fertility preservation. For working women who wish to delay childbearing, freezing eggs before the age of 35 offers the best chance of future success. In cancer patients, fertility preservation before undergoing chemotherapy or radiotherapy is becoming standard practice. Evidence shows that frozen eggs, when used within 5–10 years, can lead to pregnancy rates comparable to fresh eggs—provided they were retrieved at an optimal age and under proper protocols. The key is early counselling and timely decision-making.

How widely are advanced technologies like AI and time-lapse imaging being adopted in Indian IVF clinics, and do they improve outcomes?

Dr Mannan: Advanced technologies such as AI-based embryo selection and time-lapse imaging (like EmbryoScope) are being increasingly integrated into top-tier IVF centres in India. These tools offer real-time monitoring of embryo development and help identify embryos with the best implantation potential. AI algorithms analyse thousands of data points to assist embryologists in decision-making. While the evidence is promising—especially in reducing subjectivity and improving selection accuracy—more long-term data is needed to confirm significant improvements in live birth rates. Cost is another limiting factor, making these technologies less accessible in smaller cities.