ABSTRACT:
India is undergoing a profound demographic transition, characterized by a rapid decline in the Total Fertility Rate (TFR) to sub-replacement levels. While indicative of population stabilization, this macro-level shift masks an escalating public health crisis: a soaring prevalence of involuntary childlessness. This review synthesizes recent epidemiological data, molecular studies, and clinical trials up to 2026 to evaluate the changing etiologies of female infertility in India, focusing on metabolic disorders, environmental toxicants, lifestyle shifts, and the integration of Assisted Reproductive Technology (ART).Primary and secondary infertility now affect approximately 8% of reproductive-aged Indian women. This surge is multifactorial. Delayed motherhood contributes significantly to age-related oocyte degradation. Endocrine and inflammatory pathologies, notably Polycystic Ovary Syndrome (PCOS)—affecting up to 17.4% of urban cohorts—and endometriosis, are rising sharply. Infectious etiologies like Genital Tuberculosis (GTB) remain a "hidden epidemic." Crucially, the modern exposome, comprising elevated ambient fine particulate matter, endocrine-disrupting chemicals (EDCs), and microplastics, profoundly impairs ovarian reserve and embryogenesis. Furthermore, diets rich in ultra-processed foods (UPFs) and chronic psychosocial stress disrupt neuroendocrine pathways, further diminishing fertility. While ART and Artificial Intelligence (AI) offer advanced clinical solutions, India's recent ART (Regulation) Act, 2021 poses new socio-legal and access challenges. Reversing the infertility trend in India requires a holistic paradigm integrating precision diagnostics, rigorous environmental regulations, nutritional reform, and inclusive legislative frameworks to protect reproductive autonomy and mitigate toxicant exposure.