This chapter examines the fertility trends, patterns and preferences using data from Sri Lanka Population and Housing Censuses and Demographic and Health Surveys (DHSs). First, it investigates the fertility transition that the country has experienced during the second half of the 20th century, highlighting how social and health related factors have contributed to achieving replacement level of fertility by 2000. Second, it analyses change in marriage patterns, fertility preferences and other determinants of the recent increase in fertility. Logistic regression results highlight factors such as women’s low level of education, whether they reside in the rural or estate sector, poor economic status, and being a Moor as determining the likelihood of a desire for more than two children. Furthermore, a woman’s decision about the additional number of births was further determined by number of living children, number of living sons or daughters and exposure to mass media. The findings suggest that current fertility patterns and preferences reflect the need for strengthening the population and reproductive health policies and programmes in Sri Lanka.