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New research shows regions of the country with little to no access to fertility preservation for cancer patients


In the United States, more than 3.6 million reproductive-age women lack geographic access to an oncofertility center

Kara Goldman, MD

CHICAGO – August 10, 2023 – Certain cancer treatments, like chemotherapy and radiation therapy, can negatively impact a patient’s ability to have children. In the United States, nearly 6% of women will develop invasive cancer by the age of 50, and female cancer survivors are approximately 50% more likely to develop clinical infertility compared with noncancer survivors. Fertility preservation prior to the start of cancer treatment is an urgent and essential component of cancer care, but for many patients, geographic proximity to an oncofertility center is an obstacle.

New research published in JAMA Oncology shows that more than 3.6 million reproductive-age females lack geographic access to oncofertility services, and a geospatial analysis identified regions of the country with disproportionately low geographic access. States with fertility preservation insurance mandates, legislation making urgent egg and embryo freezing more affordable and accessible, are the same states where nearly 100% of reproductive-age women have geographic access to an oncofertility center. This study highlights stark disparities between states like Illinois, where at-risk individuals have nearly ubiquitous geographic access to care and extensive insurance mandates, and neighboring states like Missouri, Indiana, and Wisconsin, where at-risk patients struggle with limited geographic access, no insurance mandate, or both.

“Fertility preservation is a critical part of comprehensive cancer care, but procedures like egg and embryo freezing are time-intensive, expensive, and highly specialized. Given the urgent nature of fertility preservation in the face of cancer, it is critically important that patients have both geographic and financial access to this care,” said Kara Goldman, MD, corresponding author of the study, and medical director of fertility preservation at Northwestern Medicine Center for Fertility and Reproductive Medicine.


From 2021 to 2022, researchers analyzed locations of all fertility clinics identified through the 2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Report, along with data from the 2020 U.S. Census, identifying the primary at-risk population as reproductive-aged women 15 to 44-years-old. They looked at those who lived within a two-hour travel-time radius of clinics that offer fertility preservation services, and evaluated how this intersects with the state-based insurance mandates for fertility preservation coverage.

-        Among the 456 fertility clinics, 86 (19%) didn’t meet the criteria as an oncofertility center. Oncofertility centers were defined by meeting four criteria: offered oocyte and embryo cryopreservation; performed at least one fertility preservation cycle in 2018; served people without partners; and had an accredited embryology laboratory per CDC guidelines.

-        3.63 million (6%) of reproductive-age women lack geographic access to an oncofertility center.

-        99% of female patients who reside in a state with fertility preservation mandates live within two hours of an oncofertility center. Those eleven states include California, Colorado, Connecticut, Delaware, Illinois, Maryland, New Hampshire, New Jersey, New York, Rhode Island and Utah.

-        States without active or pending legislation for fertility preservation mandates have the lowest rates (80%) of eligible female patients with geographic access.

-        Researchers found entire regions of the country with little to no access to fertility preservation, including the Mountain West and West North Central regions, followed by the Southwest and West Virginia. States with the lowest percentages include Montana (24%), Wyoming (32%) and North Dakota (49%).

“By integrating geographic and legal considerations into our analysis, we were able to identify regions of the country that are currently underserved,” said Nivedita Potapragada, co-first author of the study and a medical student at Northwestern University Feinberg School of Medicine. “Our analysis highlights the importance of addressing these geographic disparities, especially with the demand for oncofertility services continuing to grow."

Dr. Kara Goldman meets Shelly Battista's twin daughters


Illinois represents one of the states with the highest percentage of reproductive-aged patients (99%) who live within a two-hour travel-time radius of an oncofertility center. Because of Illinois’ insurance mandate, Illinois residents have both geographic access and a higher chance of insurance access than most other states.

For patients like Shelly Battista, being diagnosed with breast cancer at the age of 34 was terrifying, but knowing she was near an oncofertility center in a state with an insurance mandate was reassuring.

“Following my diagnosis of breast cancer, accessibility for fertility treatment was seamless and stress free. I was lucky enough to live less than an hour from Northwestern Medicine and to not have the additional financial stress,” said Battista. “My fertility treatment (medications, egg retrieval, and transfers) were all covered by my insurance once my out-of-pocket was met. It would be unbearable to have to make a decision about my future family building based on financials due to a lack of insurance coverage. I consider myself very lucky.”

Battista’s care team was able to freeze eight embryos (fertilized eggs) before she started cancer treatment. On December 9, 2022, exactly two years to the day after she was declared cancer-free, Battista delivered identical twin girls at Northwestern Medicine Prentice Women’s Hospital.

“Shelly only has her beautiful baby girls because she had access – both geographically and financially (due to the Illinois insurance mandate) – and now we've quantified exactly who lacks this access and how we can strategically identify locations that desperately need access,” said Dr. Goldman. “Infertility remains one of the most common complications resulting from cancer treatment, and all patients – regardless of where they live or their ability to pay – should have access to fertility preservation and the chance to build a family.”

To hear Dr. Goldman discuss the study, listen to the JAMA Oncology podcast

To learn more about oncofertility services at Northwestern Medicine, visit