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Secondary infertility is becoming an important public health concern in India. Analysis of National Family Health Survey (NFHS) data indicates that its prevalence increased from 19.5% in the early 1990s to 28.6% during 2015–16, highlighting the need for greater policy attention to reproductive healthcare.

Understanding Infertility

The World Health Organization (WHO) defines infertility as a disease of the male or female reproductive system in which pregnancy is not achieved after 12 months or more of regular, unprotected sexual intercourse. Globally, one in every six individuals of reproductive age experiences infertility during their lifetime.

Infertility is classified into two types:

• Primary Infertility: The individual or couple has never achieved pregnancy.
• Secondary Infertility: Pregnancy was achieved previously, but conception does not occur subsequently despite regular unprotected intercourse.

Why is Secondary Infertility Increasing?

The rise in secondary infertility reflects the interaction of demographic, biological and environmental factors rather than a single medical cause.

Increasingly, couples are delaying family completion because of career aspirations, urbanisation and financial considerations. As many women attempt a second pregnancy after the age of 35 years, declining ovarian reserve and egg quality reduce fertility, while advancing paternal age also affects sperm quality.

Complications following the first pregnancy further contribute to infertility. Rising caesarean deliveries may result in pelvic adhesions or isthmocele, while untreated postpartum infections can lead to Pelvic Inflammatory Disease (PID) and tubal blockage. Disorders such as endometriosis, uterine fibroids, PCOS and thyroid dysfunction may also progress over time, reducing reproductive potential.

Lifestyle changes, including obesity, sedentary habits, smoking, alcohol consumption and chronic stress, alongside exposure to air pollution, microplastics and endocrine-disrupting chemicals (EDCs), are increasingly affecting fertility in both men and women. Notably, male infertility remains an under-recognised contributor despite declining sperm quality being a major cause of secondary infertility.

Challenges

India's response remains constrained by high treatment costs, inadequate public fertility services, concentration of ART facilities in private urban hospitals, and limited insurance coverage under AB-PMJAY. The Surrogacy (Regulation) Act, 2021 further restricts options for couples already having a surviving child. Social stigma surrounding infertility—particularly male infertility—and misinformation regarding fertility treatments continue to delay timely diagnosis and evidence-based care.

Government Initiatives

Key initiatives include:

• Assisted Reproductive Technology (Regulation) Act, 2021
• Surrogacy (Regulation) Act, 2021
• Jiyo Parsi Scheme
• ESIC IVF Scheme
• CGHS IVF Reimbursement
• State-supported ART/IVF programmes in Goa, Tamil Nadu and Rajasthan

Way Forward

Addressing secondary infertility requires integrating infertility care into RMNCH A and AB-PMJAY, strengthening ART services in public hospitals, promoting early screening for both partners, regulating fertility clinics effectively, and reducing stigma through awareness campaigns. A rights-based approach that protects reproductive autonomy under Article 21 will be essential to ensuring equitable access to fertility care.