CONTEXT:While the literature suggests women with diminished ovarian reserve may have increased metabolic risk, implications for long-term health are unknown. OBJECTIVE:This work aimed to investigate the relationship between ovarian reserve markers at baseline with a subsequent measure of endothelial dysfunction, as a proxy for cardiovascular risk. METHODS:This prospective cohort study was conducted in a community-based setting. Participants included 322 individuals from the Ovarian Aging Study (OVA), a National Institutes of Health-funded study of ovarian aging (average age 35.4 years at the time of baseline ovarian reserve measurements, and age 45.1 years at the time of endothelial dysfunction measurement). This study investigated the association of ovarian reserve markers at baseline with a subsequent (average of 9.7 years) assessment of cardiovascular risk using the Endothelial and Peripheral Arterial Tone reactive hyperemia index (RHI) score of endothelial function. Secondary outcomes including the American Heart Association PREVENT score, metabolic syndrome, telomere length, and mitochondrial DNA were evaluated. RESULTS:RHI as a continuous outcome was significantly positively associated both with antimüllerian hormone (AMH) and antral follicle count (AFC) on fully adjusted models (AMH coefficient 0.052; 95% CI, 0.008-0.096; P = .02; AFC coefficient 0.017; 95% CI, 0.001-0.032; P = .04). For secondary outcomes, the only result that was statistically significant was the association of fully adjusted AFC with metabolic syndrome (odds ratio 0.92; 95% CI, 0.86-0.99; P = .02). A sensitivity analysis of the premenopausal cohort (N = 246) had similar findings. CONCLUSION:In this longitudinal cohort of women with normal ovarian aging, baseline ovarian reserve markers of AMH and AFC were positively associated with endothelial function as a continuous outcome. Baseline ovarian reserve markers were not related to most secondary outcomes of cellular aging and metabolic risk.

Objective: To study measures of endothelial health, cardiovascular risk, and cellular aging between patients with polycystic ovary syndrome (PCOS) and a reproductive age normative cohort. Subjects: Community-based patients with PCOS and a normative ovarian aging cohort as controls, aged <= 45 years at the time of evaluation. Exposure: Noninvasive measure of endothelial health measured by the EndoPAT reactive hyperemia index. Main Outcome Measures: Reactive hyperemia index as measure of endothelial health. The secondary outcomes included Framingham score, telomere length, and mitochondrial deoxyribonucleic acid copy number from leukocyte cells. Results: Our cohort included 63 participants with PCOS and 130 non-PCOS participants. The mean age was significantly lower in the PCOS cohort (33.1; standard deviation, 4.7 years) than in the non-PCOS cohort (40.8; standard deviation, 2.9 years). In multivariableadjusted models, we found that PCOS was significantly associated with endothelial dysfunction as both categorical (odds ratio for PCOS, 0.31; 95% confidence interval [CI], 0.10-0.97) and continuous (PCOS coefficient, -0.37; 95% CI, -0.69 to -0.05) outcomes. For secondary outcomes, PCOS status was not significantly associated with mitochondrial deoxyribonucleic acid (PCOS coefficient, -48.1; 95% CI, -175.0 to 78.9), telomere length (PCOS coefficient, 0.05; 95% CI, -0.05 to 0.15), Framingham score (PCOS coefficient, 0.002; 95% CI, -0.01 to 0.02), or metabolic syndrome (odds ratio for PCOS, 1.29; 95% CI, 0.31-5.44). Conclusion: Our findings suggest that patients with PCOS have impaired endothelial function compared with non-PCOS patients, although measures of cellular aging and cardiovascular risk as measured by the Framingham score did not differ between the cohorts. (Fertil Steril (R) 2025;123:1123-32. (c) 2025 by American Society for Reproductive Medicine.) El resumen est & aacute; disponible en Espa & ntilde;ol al final del art & iacute;culo.

In this Perspective we share the personal story of a 33-year-old patient diagnosed with metastatic breast cancer and her journey through fertility preservation, surrogacy, and eventually motherhood, highlighting misconceptions about fertility preservation in this population. There are nearly 1 million women under the age of 50 diagnosed and living with cancer in the USA. These patients are met with life-altering decisions, including those that may limit their reproductive ability. While there have been tremendous advances and advocacy in the field of oncofertility, there has been limited focus on patients with advanced stage or metastatic cancer. We describe five key misconceptions surrounding fertility preservation in patients with advanced stage cancer, offering a review of the literature and our approach to challenging topics like desiring fertility preservation in the face of Stage 4 disease, the safety and timing of ovarian stimulation during cancer treatment, and passing away following fertility preservation. We review the importance of assessing perceptions of fertility preservation in patients with metastatic cancer and highlight the lack of research in this area as a call to action.

Abstract Disclosure: C. Kim: None. P. Schreiner: None. D. Siscovick: None. A. Wang: None. M. Wellons: None. I. Ebong: None. T. Vu: None. D. Appiah: None. J. Catov: None. E. Schisterman: None. Z. Yin: None. C.E. Lewis: None. Background Polycystic ovary syndrome (PCOS) is thought to be common, but may be underrecognized by women and their healthcare providers. Factors related to women’s self-report of PCOS diagnosis are not well-understood, particularly in population-based studies that are not based on specialist referrals. Objective To compare characteristics of women with self-reported PCOS vs. women who may have unrecognized PCOS vs. women without PCOS. We hypothesized that women who have classic PCOS characteristics, including hyperandrogenemia symptoms and cardiometabolic disorders, would be associated with higher self-report of PCOS, and that poorer social determinants of health (SDH), such as barriers to medical care, would be associated with unrecognized PCOS. Study design Analysis of an observational cohort study, the CARDIA Study. CARDIA is a population-based multi-center study that enrolled Black and White participants beginning in 1985-1986. Included in this analysis were women (n=2028) who responded to the question, “Did a doctor or nurse ever tell you that you had polycystic ovarian syndrome or polycystic ovarian disease?” at the Year 15 examination, when they were ages 33-45 years. Women who answered “yes” were defined as having self-reported PCOS. Women who answered “no or not sure” were defined as having unrecognized PCOS if they also had irregular menses between 20-30 years of age and hyperandrogenemia (defined as hirsutism or biochemical elevations in free testosterone or total testosterone) between 20-30 years of age. Exposures of interest included SDH, symptoms including irregular menses and hirsutism, and comorbid conditions including obesity and diabetes. Results: Forty-three (2.1%) of women had self-reported PCOS, 135 (6.7%) had unrecognized PCOS, and 1850 (91%) women were without PCOS. In polychotomous logistic regression models adjusting for age, race, and center, women with self-reported PCOS had greater odds of having obesity (OR 1.83, 95% CI 1.22, 2.75) and diabetes (OR 2.37, 95% CI 1.05, 5.33) compared to women without PCOS. Results were similar when women without biochemical androgens were excluded. Women with unrecognized PCOS were more likely to have hypertension (OR 1.68, 95% CI 1.03, 2.74) and food insecurity (OR 1.94, 95% CI 1.25, 3.01) but had similar likelihood of obesity and diabetes compared to women without PCOS. However, other SDH such as access to care and low education were not associated with self-report of PCOS nor with unrecognized PCOS. Conclusions Unrecognized PCOS is more common than self-reported PCOS. Women with self-reported PCOS have classic metabolic symptoms, while those with unrecognized PCOS have less traditional factors including hypertension and food insecurity. Presentation: Friday, June 16, 2023

Background Polycystic ovary syndrome (PCOS) is underdiagnosed, but factors associated with women’s report of diagnosis are not well-understood, particularly social determinants of health. Therefore, in a population-based cohort, we compared the characteristics of women with self-reported PCOS vs. women who have unrecognized PCOS vs. women without PCOS. Methods We performed a secondary data analysis of the Coronary Artery Risk Development in Young Adults (CARDIA) Study, a population-based, prospective cohort of Black and White women. Participants were women (n = 2028) who responded to the question, “Did a doctor or nurse ever tell you that you had polycystic ovarian syndrome or polycystic ovarian disease?” at the year 15 examination. Women who answered “yes” were defined as having self-reported PCOS. Women who answered “no or not sure” were defined as having unrecognized PCOS if they also had irregular menses and hyperandrogenemia between 20 and 30 years of age. Exposures of interest included social determinants of health, symptoms including irregular menses and hirsutism, and comorbid conditions. Results Forty-three (2.1%) of women had self-reported PCOS, 135 (6.7%) had unrecognized PCOS, and 1850 (91%) women were without PCOS. In logistic regression models adjusting for age, race, and center, women with self-reported PCOS were more likely to have obesity (OR 1.83, 95% CI 1.22, 2.75) and diabetes (OR 2.37, 95% CI 1.05, 5.33) compared to women without PCOS. Women with unrecognized PCOS were more likely to have hypertension (OR 1.68, 95% CI 1.03, 2.74) and food insecurity (OR 1.94, 95% CI 1.25, 3.01) compared to women without PCOS. Conclusions Unrecognized PCOS is common. Self-report of PCOS is not associated with access to healthcare. Women who report PCOS are more often obese and comorbidities may contribute to recognition of PCOS.

Fertility treatment has been deemed "medically necessary" by the WHO, AMA, and ASRM. Only fourteen states have mandated coverage for in vitro fertilization (IVF). In many states, patients can appeal insurance denials through centralized governmental independent medical review (IMR) processes. In California, the appeals process is governed by the Department of Managed Healthcare (DMHC). Since its inception in 2001, 68% of insurance denials have been overturned. The purpose of this study was to characterize fertility-related IMR cases and evaluate their success rates to inform and educate physicians on best practices in utilizing the IMR process to expand access to care. The publicly accessible DMHC IMR database of cases submitted between 2001 and 2023 was reviewed. All cases categorized as related to obstetrics and gynecology, urology, endocrinology, and cancer were reviewed. Additional fertility-related cases were identified by a standardized keyword search algorithm. Data on clinical history, coverage requested, duration of the appeals process, and reviewer characteristics were collected. Descriptive statistics were performed in STATA SE 17.0. A total of 34,616 IMR cases were filed between 2001 and 2023. Of these, 133 cases pertained to fertility care. DMHC overturned 47% of insurance plan denials. Insurance denials were upheld when cases were deemed medically unnecessary or experimental by medical society guidelines and peer-reviewed literature. Patients filed cases to obtain coverage for evaluation and treatment of infertility (29% of cases, 60% overturned), recurrent pregnancy loss (20% of cases, 0% overturned), uterine pathology (14% of cases, 36% overturned), and genetic conditions (14% of cases, 89% overturned). More specifically, patients sought coverage for physician consultation fees (21%), diagnostic testing (15%), surgery (15%), and treatments (48%, including intrauterine insemination and IVF). All carriers of disease-causing mutations (e.g., cystic fibrosis) were successful in obtaining coverage for in vitro fertilization with preimplantation genetic testing (PGT). Seventeen percent of cases were submitted for cancer-associated fertility preservation (FP) coverage. Almost all insurance denials --91%--were overturned. Cancer patients were universally successful in obtaining coverage for cryostorage fees, subsequent IVF cycles in the case of poor initial outcome, and PGT for cancer-causing mutations. Denials occurred only in cases in which the cancer treatment was not known to cause iatrogenic infertility. Almost 50% of patients successfully obtained fertility coverage when they initially had none. The DMHC IMR process and analogous processes in other states should be systematically utilized to obtain insurance coverage for medically necessary fertility care, even in the absence of state-mandated fertility coverage legislation.

To investigate if differences in self-reported satisfaction with fertility clinics and doctors differ by race/ethnicity. We used cross-sectional survey data from FertilityIQ online questionnaires completed by patients receiving US. fertility care from July 2015 to December 2020. Univariate and multivariate logistic and linear regression analyses were performed to assess association of race/ethnicity on patient-reported clinic and physician satisfaction. Our total sample size included 21,472 unique survey responses (15,986 Caucasian, 1856 Black, 1780 LatinX, 771 East Asian, 619 South Asian, 273 Middle Eastern, 187 Native American self-reported). When adjusting for potential confounders (demographic and patient satisfaction), we found that Black patients rated their doctors more highly (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.04–1.62 p = 0.022 logistic and Coefficient 0.082, 95% CI 0.013–0.15 p = 0.02 linear), while other ethnic groups did not show significant differences compared to Caucasian patients. East Asians had borderline lower satisfaction with clinic satisfaction in logistic regression (OR 0.74 95% CI 0.55–1.00 p = 0.05), while significant differences were not found for other ethnic groups for clinic satisfaction. In summary, some but not all minority groups differed in their self-reported perception of satisfaction with fertility clinic and doctors compared to Caucasian patients. Cultural differences towards surveys may contribute to some of these findings, and satisfaction by racial/ethnic group may also be modified by results of care.

Objective:To study the impact of vigorous vs. moderate exercise on metabolic parameters in polycystic ovary syndrome (PCOS). Design:Randomized controlled trial. Setting:Unsupervised home-based exercise program. Patients:Patients with PCOS on the basis of the Rotterdam criteria with insulin resistance. Interventions:Participants were block randomized to a home-based exercise program of 75 minutes of vigorous exercise or 150 minutes of moderate exercise per week, for 8 weeks total. Main Outcome Measures:Changes in glucose, insulin, and insulin resistance. Results:In total, 36 participants were randomized, of whom 20 completed the study. The percentage changes from baseline at 4 and 8 weeks for fasting glucose, insulin, and homeostatic model assessment for insulin resistance did not significantly differ between the groups, except for the change in the 8-week glucose level, which was more favorable in the moderate arm (8.06% [standard deviation, 6.44%] in the vigorous group compared with -0.32% [standard deviation, 4.91%] in the moderate group). The absolute values of the main outcomes (fasting glucose, insulin, and homeostatic model assessment for insulin resistance) at baseline and 4 and 8 weeks did not significantly differ between trial arms. When assessing the change from baseline at 4 and 8 weeks, overall and within each trial arm, only the 8-week fasting glucose level was significantly greater than the baseline value in the vigorous arm (93.5 [95% confidence interval, 88.7-98.3] vs. 86.8 [95% confidence interval, 81.1-92.4]). Conclusions:Unsupervised short-term exercise programs may not achieve significant metabolic improvements in patients with PCOS, regardless of vigorous vs. moderate intensity. Future studies should investigate this question in larger sample sizes and longer or structured exercise programs. Clinical Trial Registration Number:ClinicalTrials.gov identifier, NCT02303470.

The World Professional Association for Transgender Health, Endocrine Society, and American Society of Reproduction all recommend counseling transgender men on Assisted Reproductive Technologies (ART) and fertility preservation (FP) before initiation of gender-affirming treatment (GAT) (1). As a result, there is a growing number of adolescents on pubertal suppressive agents presenting for discussion of FP (2,3). Pubertal suppression with a GnRH agonist has been well-documented as reversible, allowing reactivation of pubertal development and secondary sexual characteristics consistent with natal sex upon cessation of treatment (4,5,6). The practicality of cryopreservation of oocytes is uncertain in patients who have not completed puberty. There are two published reports of prepubescent adolescents who underwent controlled ovarian stimulation (COS) while still on GnRH agonist pubertal suppression (7,8).

To investigate whether participants in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort with polycystic ovary syndrome (PCOS) differ for incidence rates of cancer and/or time to develop cancer compared to participants without PCOS.

To investigate if breast cancer stage and grade affect fertility preservation outcomes. We performed a retrospective cohort study that included premenopausal women with breast cancer undergoing fertility preservation diagnosed between January 2011 and January 2019. The primary outcome measure was the number of mature oocytes (MII) per antral follicle count (AFC). Secondary outcome measures included total oocytes retrieved, total mature oocytes retrieved, and greater than 10 mature oocytes preserved. Univariate and multivariate models were used to assess the association of low vs. high stage (low stage I–II and high stage III–IV) and grade I vs. grade II/III with each outcome, with adjustment for confounders. A total of 267 premenopausal breast cancer patients undergoing fertility preservation were included in our study, with the majority presenting with low stage (N = 215, 80.5%), grade II/III (N = 235, 88.1%) disease. Baseline AFC, total gonadotropin dose, days of stimulation, and follicles $$\ge$$ 13 mm on the day of trigger did not differ by stage or grade. After adjusting for age, BMI, and baseline AFC, we found that the mean MII per AFC did not differ by stage (1.0 vs. 1.1, P = 0.3) or grade (1.0 vs. 1.0, P = 0.92). Similarly, total oocytes retrieved, total MII retrieved, and percentage of patients who were able to preserve greater than 10 MII did not differ by breast cancer stage or grade (all P > 0.2). Breast cancer grade and stage do not impact ovarian stimulation or fertility preservation outcome.

To determine if a fertility preservation consult is associated with anxiety and distress among an oncofertility cohort, and if these levels differ based on fertility preservation status.

To investigate the incidence of and time to development of cardiovascular events and multiple metabolic outcomes (hypertension, hyperlipidemia, diabetes) by polycystic ovary syndrome (PCOS) status among participants in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort.

In this secondary analysis of the TAmoxifen or Letrozole in Estrogen Sensitive tumors (TALES) trial, we aimed to investigate if concurrent administration of letrozole vs. tamoxifen vs. no added treatment affects hormonal composition and size of stimulated ovarian follicles. TALES is a randomized controlled trial of IVF stimulation for estrogen receptor (ER)–positive breast cancer patients stimulated with gonadotropins and administered concurrent tamoxifen 20 mg or letrozole 5 mg. We analyzed estradiol (E2), testosterone (T), progesterone (P4), follicle stimulating hormone (FSH), luteinizing hormone (LH), and anti-Mullerian hormone (AMH). We used ANOVA/Kruskal–Wallis, logistic, and linear regression models to examine differences in follicular hormone levels, size, and mature oocyte yield between trial arm. We included data from total 246 follicles (94 letrozole, 82 tamoxifen, and 70 control) from 123 unique participants. E2 was lower (letrozole 187.4, tamoxifen 1026.0, control 821.5 ng/mL, p < 0.01) and T was higher (letrozole 2489, tamoxifen 571, and control 504 ng/mL, p < 0.03) in the letrozole group compared to tamoxifen and control groups, while other hormone levels and follicle size were similar across groups. There were no significant differences in hormone concentrations within the follicle between tamoxifen and control arms. On multivariate logistic regression, there was no significant association of mature oocyte yield by follicle size, hormone levels, or trial arm. Concurrent administration of letrozole with gonadotropins affects follicular E2 and T concentrations compared to tamoxifen/control. Tamoxifen was not associated with any differences in hormone concentrations within the follicle. Mature oocyte yield was similar across groups.

Prior research has suggested that fertility clinics vary in terms of displaying online content specific to lesbian, gay, bisexual, and transgender (LGBT) patients, and literature on assisted reproductive technologies (ART) disparities in this population is limited.

To determine whether concomitant tamoxifen 20 mg with gonadotropins (tamoxifen-gonadotropin) versus letrozole 5 mg with gonadotropins (letrozole-gonadotropin) affects mature oocyte yield. Open-label, single-institution, randomized trial. Inclusion criteria included the following: females, ages 18–44 years old, with new diagnosis of non-metastatic breast cancer, who were undergoing fertility preservation with either oocyte or embryo cryopreservation. Those with estrogen-receptor-positive (ER+) breast cancer were randomized to tamoxifen-gonadotropin or letrozole-gonadotropin. Another group with estrogen-receptor-negative (ER−) breast cancer was recruited, as a prospectively collected comparison arm who took neither letrozole nor tamoxifen (gonadotropin only). The primary outcome was the number of mature oocytes obtained from the cycle. The randomized groups were powered to detect a difference of three or more mature oocytes. Forty-five patients were randomized to tamoxifen-gonadotropin and fifty-one to letrozole-gonadotropin. Thirty-eight patients completed gonadotropin only. Age, antral follicle count, and body mass index were similar between the randomized groups. Our primary outcome of mature oocyte yield was similar between the tamoxifen-gonadotropin and letrozole-gonadotropin groups (12±8.6 vs. 11.6±7.5, p=0.81, 95%CI of difference =−2.9 to 3.7). In a pre-specified secondary comparison, mature oocyte yield was also similar with tamoxifen-gonadotropin or letrozole-gonadotropin versus gonadotropin only (12±8.6 vs. 11.6±7.5 vs. 12.4±7.2). There were no serious adverse events in any of the groups. Tamoxifen-gonadotropin and letrozole-gonadotropin produced a similar number of mature oocytes. Women who received either tamoxifen-gonadotropin or letrozole-gonadotropin had a similar number of oocytes to the gonadotropin-only group. NCT03011684 (retrospectively registered 1/5/2017, after 9% enrolled)

Prior literature has suggested that follicular fluid hormonal milieu may affect oocyte yield/quality. In this secondary analysis of the TAmoxifen or Letrozole in Estrogen Sensitive tumors (TALES) trial, we aimed to investigate if concurrent administration of letrozole vs tamoxifen vs no added treatment affects hormonal composition and size of stimulated ovarian follicles. TALES is a randomized controlled trial of IVF stimulation outcomes for non-metastatic estrogen receptor (ER) positive breast cancer patients stimulated with gonadotropins, randomized to concurrent administration of tamoxifen 20 mg, letrozole 5 mg, or no added treatment (for ER negative controls). We investigated characteristics of the largest follicle on both sides in terms of 6 different hormones: FSH, LH, E2, P4, Testosterone (T), and AMH. These hormones were chosen based on literature suggesting possible effect on follicular/oocyte development, as well as biologic plausibility to be affected by the mechanism of letrozole or tamoxifen. We used ANOVA/Kruskal-Wallis, logistic, and linear regression to examine differences in follicular hormone levels and size between trial arms, and the relationship between these metrics and mature oocyte yield. We included data from total 246 follicles (94 letrozole, 82 tamoxifen, and 70 control) from 123 unique participants, with average age 34.0 years. E2 (p<0.001, significantly lower in letrozole group) and T (significantly higher in letrozole group, p=0.03) were significantly different between the groups, while other hormone levels and follicle size were similar (see Table below). There was no significant association of mature oocyte by follicle size, hormone levels, or trial arm. Concurrent administration of letrozole with gonadotropins affects follicular E2 and T concentrations compared to Tamoxifen/control. Tamoxifen follicular fluid hormone concentration is similar to control. Mature oocyte yield is similar across groups.

Prior studies have demonstrated increased rates of anxiety and depression symptoms in patients undergoing infertility treatment. Meanwhile, little is known regarding the prevalence of these symptoms among patients undergoing planned oocyte cryopreservation (OC) to offset the anticipated risk of infertility. We sought to characterize anxiety and depression symptoms among planned OC patients and to compare these measures to an infertility cohort. We hypothesized that patients undergoing planned OC would have lower symptoms of depression and anxiety than infertility patients. Two prospective cohorts were included in the study: (1) planned OC (N=253) and infertility (N=448). Both cohorts were recruited from fertility clinics in the San Francisco Bay Area between 2018-2020 and 2000-2004, respectively. All patients were assessed prior to undergoing their first cycle of planned OC or IVF, respectively. Validated scales were used to ascertain depression symptoms (Center for Epidemiologic Studies Depression scale, CESD) and anxiety symptoms (as State Anxiety subscale of the State-Trait Anxiety Inventory, STAIS). CESD and STAIS were investigated as both continuous and categorical variables, with cutoffs defined as CESD≥16 and STAIS≥39 to indicate clinically significant symptoms in accordance with prior literature. These outcomes were analyzed in relation to OC/infertility treatment while adjusting for confounders determined a priori including age, income, race, and history of prior pregnancy. Compared to the infertility cohort, OC patients were slightly younger (34.9 vs 35.8 years), more highly educated, reported higher income (85.7% vs 66.2% with greater than $100K income), less likely to be Caucasian (51.6% vs 74.4%), and less likely to have had a prior pregnancy (87.1% nulliparous vs 53.8%, p<0.05 for all). Average CESD scores were 11.2 and 11.1 for the infertility/OC groups, respectively (p=0.86). Average STAIS score was slightly higher for the infertility group, 40.2 compared to 38.3 (p=0.04). Prior to starting treatment, 26% of infertility patients had clinically significant depression symptoms compared to 25% of OC patients (p=0.71), while 51% of infertility patients and 49% of OC patients had clinically significant anxiety symptoms (p=0.64). On multivariate logistic and linear regression adjusting for confounders, contrary to our hypothesis, we found that depression and anxiety symptom burden did not differ significantly between patients pursuing planned OC vs those seeking infertility treatment. A significant portion of patients undergoing oocyte cryopreservation report anxiety and depression symptoms at baseline, comparable to an infertility population. After adjustment for confounders, we found no difference between the two populations in terms of self-report of symptoms.

Background: Given the concurrence of medical residency and fellowship training with typical childbearing years, trainees often must make difficult decisions regarding family planning, requiring the support of their residency and fellowship program directors (PDs) to guide them. Objective: Our hypothesis was that PDs have knowledge gaps and varying levels of support in terms of their trainees' fertility, and the goal of our study was to assess the knowledge and support of residency and fellowship PDs in the United States toward trainees' reproductive needs. Methods: Cross-sectional survey distributed to all residency and fellowship PDs providing contact information through the Accreditation Council for Graduate Medical Education website in August 2019. Results: Of 299 respondents, the most common lengths of leave reported were 6-8 weeks of maternity leave and under 2 weeks of paternity leave. A total of 57.2% did not know their program's insurance for infertility treatment, and 68.6% did not know fertility preservation coverage. A total of 52.2% of PDs were unaware of if their trainees faced infertility. PDs supported residents' needs through moral support (68.2%) and time off for appointments (65.2%). Similarly, most PDs (66.2%) never had a trainee express interest in fertility preservation to them but offered moral support (59.2%) and time off (48.5%). Respondents felt it was important to increase resources for trainees by increasing their awareness of needs (47.5%) and establishing reproduction-related policies (34.1%). Conclusion: The study found variations regarding PDs' knowledge and support levels for trainees' fertility needs. Most were unaware of their trainees' fertility needs, and many PDs felt it would be important to improve resources by increasing personal awareness and creating policies for support to promote reproductive health equity for trainees.