Early European colonists of the Andes had difficulties in reproducing, a fact that underpins the hypothesis that reproduction is impaired amongst all humans at high altitudes. Yet a 16th century missionary wrote, “… the Indians are healthiest and where they multiply the most prolifically is in these same cold air-tempers, … [yet most children of the Spaniards] when born in such regions do not survive.” These observations suggest that humans at high altitudes are subjected to strong natural selection from hypoxia, cold and limited food sources and, furthermore, that human populations can and have adapted, and continue to adapt, to these conditions. Informed by multiple approaches and theoretical frameworks, anthropologists have investigated to what extent and precisely how high altitude environments impact human reproductive functioning and fertility. Analyses of the proximate determinants of natural fertility suggest that behaviors (breast/infant feeding practices in the Andes, and marriage practices and religious celibacy in the Himalaya) are major determinants of fertility in high altitude populations. Furthermore, data from Project REPA (Reproduction and Ecology in Provincía Aroma), a longitudinal study in rural Bolivia, demonstrate that fecundity is not impaired in this indigenous altiplano population, and that the risk for early pregnancy loss (EPL) is not elevated by environmental hypoxia but does vary seasonally with the agricultural cycle (contra to the assumption that EPLs are due almost entirely to genetically flawed concepti). This review discusses these and other findings that reveal the complex and dynamic adaptations of human reproductive functioning in high altitude environments. Am. J. Hum. Biol. 25:179–189, 2013. © 2013 Wiley Periodicals, Inc.