Monoterpene indole alkaloids (MIAs) are a large class of plant alkaloids with significant pharmacological interest. The sustained production of MIAs at high yields is an important goal in biotechnology. Intensive effort has been expended toward the isolation, cloning, characterization and transgenic modulation of genes involved in MIA biosynthesis and in the control of the expression of these biosynthesis-related genes. At the same time, considerable progress has been made in the detailed description of the subcellular-, cellular-, tissue- and organ-specific expressions of portions of the biosynthetic pathways leading to the production of MIAs, revealing a complex picture of the transport of biosynthetic intermediates among membrane compartments, cells and tissues. The identification of the particular environmental and ontogenetic requirements for maximum alkaloid yield in MIA-producing plants has been useful in improving the supply of bioactive molecules. The search for new bioactive MIAs, particularly in tropical and subtropical regions, is continuously increasing the arsenal for therapeutic, industrially and agriculturally useful molecules. In this review we focus on recent progress in the production of MIAs in transgenic cell cultures and organs (with emphasis on Catharanthus roseus and Rauvolfia serpentina alkaloids), advances in the understanding of in planta spatial-temporal expression of MIA metabolic pathways, and on the identification of factors capable of modulating bioactive alkaloid accumulation in nontransgenic differentiated cultures and plants (with emphasis on new MIAs from Psychotria species). The combined use of metabolic engineering and physiological modulation in transgenic and wild-type plants, although not fully exploited to date, is likely to provide the sustainable and rational supply of bioactive MIAs needed for human well being.