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Declining fertility due to ovarian dysfunction is a critical concern for population sustainability. Acupuncture shows potential for ovarian functional restoration, primarily mediated through its neuromodulatory effects on the hypothalamic-pituitary-ovarian (HPO) axis. Accumulating evidence from clinical and animal studies suggests that acupuncture modulates ovarian function through multiple neuroendocrine pathways. Specifically, acupuncture regulates hypothalamic activity by influencing the release of reproduction-associated neuropeptides (e.g., kisspeptin, neuropeptide Y, and gonadotropin-releasing hormone) and neurotransmitters (e.g., gamma-aminobutyric acid, serotonin, glutamate, and dopamine). Additionally, it may affect peripheral-to-central sensory nerve pathways as well as sympathetic and parasympathetic neural activity, which collectively enhance ovarian function. In this article, we comprehensively reviewed the neuroendocrine regulatory pathways through which acupuncture exerts its therapeutic effects in ovarian diseases, thereby providing a deeper understanding of the mechanisms involved and the directions for future research.