India crossed a line last year and barely paused over it. The Sample Registration System report put the country's total fertility rate at 1.9, below the replacement level of 2.1, Delhi is at 1.2, Kerala, Tamil Nadu and West Bengal are at 1.3. We went from 5.2 children per woman in 1971 to fewer than two in a single lifetime.
The response has been cheques. Andhra Pradesh now offers ₹30,000 for a third child and ₹40,000 for a fourth, and other states are considering the same.
Now the second fact. Ayushman Bharat, the largest publicly-funded health assurance scheme in the world, does not cover IVF or any assisted reproductive procedure in most states. Nor does most private insurance, which lists infertility under exclusions alongside cosmetic surgery.
Falling fertility is usually explained through education, contraception and cost of living. Much of it genuinely is choice, and mostly that is good news.
It is also incomplete. The World Health Organization estimates that around 17.5% of adults, roughly one in six, experience infertility in their lifetime, with little variation between rich and poor countries. In India, 15 to 20% of couples struggle to conceive. A meaningful share of our missing births are not decisions. They are diagnoses.
We debate the birth rate as though every uncounted child reflects a preference. When a country stops distinguishing between people who chose not to have children and people who could not, it can design policy for neither.
{{/usCountry}}We debate the birth rate as though every uncounted child reflects a preference. When a country stops distinguishing between people who chose not to have children and people who could not, it can design policy for neither.
{{/usCountry}}One IVF cycle costs ₹1.2 lakh to ₹3 lakh before a second attempt. Public cover is absent. Private cover is theatre: Riders with waiting periods of two to four years and sub-limits that can cap a ₹10 lakh policy at ₹50,000. A four-year waiting period applied to a 36-year-old woman is not an insurance term. It is a refusal written in a polite font, because ovarian reserve does not observe waiting periods.
This reaches inside every laboratory. A couple who can afford one attempt will push for the most aggressive protocol available and resist single embryo transfer, because two feels like double the odds. They delay while arranging money, and delay is the only variable in this field that cannot be recovered.
That is how an affordability problem becomes a clinical one. Twins, preterm deliveries and neonatal intensive care cost the system far more than the cycle everyone was economising on. We save at treatment and pay in the nursery.
If a country will hand out cash for a fourth child, funding two cycles for a couple who cannot have a first is not a large leap.
Vitrification turned embryo freezing from a gamble into a routine, which is why one egg retrieval can now yield several attempts rather than a single shot at success, and why transferring one embryo at a time became safe to recommend. Time-lapse incubation lets us watch development continuously without ever disturbing the culture environment. AI-assisted selection is beginning to bring consistency to a judgement that was always partly subjective. Electronic witnessing has made misidentification, the rarest and most catastrophic failure in this field, close to preventable.
Together these have changed the arithmetic. Fewer cycles per baby is the same thing as lower cost per baby, and it is the only lever that has actually moved while affordability stood still. A couple who a decade ago needed two or three full stimulations may now need one retrieval and two frozen transfers.
Which makes the case for funding stronger, not weaker. The treatment we are asking insurers and public schemes to cover today is more effective, safer and more predictable than the one they declined to cover ten years ago. The science has done its part. The financing has not moved at all.
Every clinical role around the IVF laboratory has one. Radiographers have a recognised professional category. So do medical laboratory technologists and physiotherapists. Clinical embryology, which is younger than all of them, has never been given the same standing.
This is an omission rather than a judgement on anyone. The field simply grew faster than the frameworks built to describe it, which is a familiar story in new specialties everywhere. But it leaves the person who performs ICSI and selects which embryo is transferred without a defined professional identity, at a moment when the country is asking that person to do more, better, and for more families.
India is also not short of embryology education. Master's programmes have multiplied and thousands hold the qualification.
Yet there is no standardised curriculum, no mandated minimum of supervised procedures, no logged cases, no practical exit assessment.
So, we have a workforce with degrees and uneven skill, entering laboratories where nobody is obliged to check the difference before handing over a patient's only embryo. Structured, assessed certification exists and is spreading through this region. Very little obliges an employer to ask for it.
Recognise infertility as the disease every medical authority already calls it, and cover a defined course of treatment. Give clinical embryology the professional standing every comparable role already has.
India spent 50 years persuading its citizens to have fewer children. It succeeded. It has not yet noticed that the harder problem is now the couples who want a child and cannot have one, and that the profession standing between them and that child is the one part of the health system that needs attention and support.
(The views expressed are personal)
This article is authored by Dr Keshav Malhotra, chairman of embryology, Indian Society of Assisted Reproduction Lab Director, ART Rainbow IVF, Agra.