Objectives: Over 15,000 children in the United States are diagnosed with cancer annually, with many treatments impacting future fertility. Despite increased knowledge and availability of fertility preservation interventions, individual- and systems-level barriers may affect their implementation and completion. We sought to determine associations between sociodemographic factors and rates of referral for and completion of fertility preservation interventions in pediatric hematology/oncology patients at increased risk for future gonadal failure/infertility. Methods: This single center, retrospective cohort study included children aged 0-18 who were treated at the University of Chicago between 2018-2023, all at high levels of increased risk for future gonadal failure/infertility as per the Pediatric Initiative Network Risk Stratification System. Sociodemographic (sex, pubertal status, race/ethnicity, primary language) and systems-level (insurance status, “in house” versus “outside” referral) variables were collected via electronic medical records. “Social vulnerability” was calculated using the CDC/ATSDR Social Vulnerability Index. Fertility preservation referral was defined as documented discussions about fertility risks and preservation strategies, while completion included documentation of procedures. We compared rates of fertility preservation referral and completion, as well as time to referral and completion, using Chi-squared tests and t-tests. Results: 143 participants were included for analysis (62% male, 39% white, 21% Hispanic/Latine, mean age 9.1±7.1 years). 87 (61%) of participants received fertility preservation referrals, and 47 (54%) completed a procedure. No associations were observed between sociodemographic or systems-level factors and rates of referral or completion. Males had a longer time to referral from diagnosis compared to females (p=0.01). Non-white participants experienced longer times from diagnosis to referral (p=0.03) and completion (p=0.04) compared to white participants. Conclusions: Fertility preservation referral and completion rates in pediatric patients remain suboptimal. Sociodemographic and systems-level factors may be less influential than previously thought, indicating the need for further research to understand and address factors affecting fertility preservation rates.