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Monoterpene indole alkaloids (MIAs) constitute a large group of specialised metabolites with many potent pharmaceutical properties, including the antitumoral vinblastine and hypotensive ajmalicine. Hence a large body of phytochemical investigation delineates the distribution and diversity of various MIA structural classes in Gentianales families. The biosynthetic pathway of these secondary metabolites involves several specific branches, including indole and monoterpenoid formations, secoiridoid assembly, central MIA biosynthesis and branch-specific reactions, as well as supply of primary metabolite precursors by the methylerythritol phosphate and shikimate pathways. Several genes and enzymatic activities involved in these pathways have been characterised, allowing detailed analysis of the molecular biology of this system in model plants such as Catharanthus roseus and Rauvolfia serpentina. With the prospects of improving production of MIAs in plant and cell culture, regulations of biosynthetic capacities have been thoroughly investigated. This pathway also presents a high degree of spatial organisation at the organ, cellular and subcellular levels. This chapter presents an overview of the structural diversity, the complexity of MIA biosynthesis, and regulation with an evolutionary perspective.