The occurrence of pharmaceutical compounds, especially non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, in aquatic ecosystems has emerged as a major environmental issue. Ibuprofen is commonly found in water bodies and presents potential risks to aquatic organisms, particularly fish, by inducing biochemical disturbances and genetic damage. This review compiles existing knowledge on the effects of ibuprofen exposure in fish, with emphasis on oxidative stress, hepatic and renal dysfunction, metabolic alterations, endocrine disruption, and genotoxic impacts. Exposure to ibuprofen leads to elevated production of reactive oxygen species (ROS), disruption of antioxidant defense systems, and impairment of vital organs such as the liver and kidneys. Additionally, endocrine-related effects include hormonal imbalances and compromised reproductive functions. Growing evidence also indicates the genotoxic nature of ibuprofen, demonstrated through DNA damage, micronuclei formation, and chromosomal abnormalities. The prolonged and sub-lethal effects of these changes may significantly influence fish health, population stability, and overall aquatic ecosystem integrity. Therefore, improving wastewater treatment processes and enforcing stricter environmental regulations are essential to reduce the impact of ibuprofen and related contaminants in aquatic environments.