Fertility care equity in India: access, cost, and the gaps

India's fertility care landscape is primarily private. Government hospital fertility services exist but are limited in number, concentrated in major cities, and frequently have long waiting times. The practical implication is that fertility care in India is predominantly available to people who can pay out-of-pocket, creating a significant access gap along economic and geographic lines.

Most IVF capacity is concentrated in Tier 1 cities: Mumbai, Delhi, Bangalore, Chennai, Hyderabad, Pune, and Kolkata. Tier 2 and Tier 3 cities are underserved, as are rural areas. For women and couples in smaller cities or rural settings, accessing specialist fertility care typically involves travel costs on top of treatment costs, and time away from work.

NRI and diaspora patients from the UK, US, Gulf, and other countries who travel to India for fertility treatment typically access care in Tier 1 cities. Their experience of the system is often more resourced than that of lower-income Indian patients accessing the same clinics.

India has a high and rising rate of secondary infertility, infertility in couples who have had at least one previous pregnancy. National data shows an increase from 19.5% in 1992–93 to 28.6% in 2015–16. This increase is attributed to a range of factors including rising rates of obesity, type 2 diabetes, reproductive tract infections, and age at second pregnancy.

Secondary infertility carries a different social weight than primary infertility. Couples with one child who are struggling for a second may receive less social support, the perception that they already have a child can minimise the significance of the difficulty they are experiencing. This is worth naming: secondary infertility is a real clinical entity with the same investigation and treatment pathways as primary infertility.

Several trends are improving access at the margin: fertility clinic expansion into Tier 2 cities; telemedicine consultations that allow initial workup and follow-up without travel; some government state health insurance schemes beginning to cover fertility investigations (though rarely treatment); and growing employer coverage of fertility benefits at large corporate employers.

Clinical research that reflects India's diversity, not just Tier 1 city hospital populations, matters for generating evidence that applies to the full range of Indian women and couples. The national data gaps in South Asian subgroup fertility research (Punjabi, Gujarati, Bangladeshi, Tamil, Sri Lankan Tamil) represent both a research gap and an advocacy opportunity.

Knowing the landscape does not change it. But it does allow you to navigate it with more information, knowing what to ask, what to check, and what barriers are structural rather than personal.