Legislation on Medical Fertility Preservation: Improved but Insufficient Access to Care in Disadvantaged Neighborhoods.

Objective: To assess whether state-level legislation mandating insurance coverage for medical fertility preservation (MFP) was associated with a change in the neighborhood disadvantage of individuals accessing fertility preservation care. Methods: This is a retrospective cohort study of individuals with ovaries seen for MFP consultation from 2017 to 2020 at a large academic medical center. Neighborhood disadvantage, as measured by median area deprivation index (ADI) in those who had MFP consultation and initiated ovarian stimulation for MFP was assessed; insurance type and other demographics were also assessed. Patients who underwent ovarian stimulation in 2017-2018 (pre-legislation) were compared to those who underwent stimulation between 2019 and 2021 (post-legislation). Results: Overall, 427 individuals with ovaries were seen for MFP consultation from 2017 to 2020; 203 of which were seen prior to legislation mandating insurance coverage (2017-2018), and 224 were seen following expansion of legislation (2019-2020). Overall, 278 individuals initiated ovarian stimulation cycles for MFP, 122 pre-legislation and 156 post-legislation. More patients with Medicaid insurance coverage were seen for MFP consultation and initiated stimulation post-legislation than pre-legislation (28 versus 12 for consultation, p = 0.020; 17 versus 3 for stimulation, p = 0.007). The predicted median ADI of patients initiating stimulation was 8 points higher post-legislation, representing increased neighborhood disadvantage, though this difference did not reach statistical significance (p = 0.053). After adjusting for other sociodemographic factors, the predicted median ADI of patients initiating stimulation was 3.5 points higher post-legislation (p = 0.25). Conclusions: While the implementation of an insurance mandate for MFP increased the median ADI of those initiating stimulation, this difference was not statistically significant. Legislation alone may not be enough to expand access to care to those living in the most disadvantaged areas.