Preparing for California’s Fertility Mandate: Insights from Stanford Medicine
With California’s fertility mandate on the horizon, clinics across the state are preparing for a significant increase in fertility patients. We sat down with Dr. Ruben Alvero, Division Chief of Reproductive Endocrinology and Infertility at Stanford Medicine, to talk about how one of the nation’s leading academic centers is preparing for the expected surge in demand - and what lessons other clinics and states can take from their approach.
August 8, 2025 | 3 mins
About the expert
Dr. Ruben Alvero
Stanford University School of Medicine
Dr. Ruben Alvero is Professor of Obstetrics and Gynecology at Stanford Medical School and is the Division Director of Reproductive Endocrinology and Infertility at the Lucille Packard Children’s Hospital. He had been lobbying for the fertility mandate in California for a long time and helped frame the narrative, highlight patient needs, and reinforced the public health rationale for mandating fertility coverage.
Silvia
Let’s get right to the point: How is your clinic at Stanford preparing for the upcoming fertility mandate?
Dr. Ruben Alvero
As soon as the bill passed in late 2023, I began thinking about what it would mean for our clinic at Stanford. We're expecting a gradual influx of patients over the next three years, not a sudden spike. Based on economic modeling we did during lobbying, we estimate our cycle volume will increase from about 1,300 to 1,800–1,900 annually. That’s an increase of 500–600 cycles over three years. Since insurance plans typically renew late in the year, coverage likely won’t kick in for most people until January 2026. But even then, we expect to see an uptick starting immediately.
To prepare, we’ve started scaling our workforce - attempting to recruit more reproductive endocrinologists, advanced practice providers, nurse practitioners, and ultrasonographers. The challenge is that REIs are in short supply nationally. We’ve been advocating for more fellowship slots for years, but it’s a slow process. So we’re relying more heavily on APPs as well as our OB-GYN referral network. I would recommend that other clinics also invest in a good relationship with their referring providers.
Silvia
What do you mean by that, exactly?
Dr. Ruben Alvero
OB-GYNs will be absolutely critical with the new mandate. We’ve been working to empower non-REI providers to perform basic fertility assessments and make smarter referrals. One of the best things an OB-GYN can do is send a patient to an REI fully worked up. That means testing is already complete when the patient arrives at the fertility clinic, which allows us to move to treatment within 4–6 weeks instead of waiting three months just to get started.
Silvia
What’s needed to prepare OB-GYNs for this role?
Dr. Ruben Alvero
We’ve created a detailed protocol book for diagnostic workups and share it freely with referring providers. It’s been built across multiple IVF centers I’ve worked at. When OBs follow it, patients show up with everything done: labs, imaging, semen analysis - ready to go. It’s beautiful when that happens, and we want more of that.
We also see value in OBs handling basic treatments in straightforward cases, especially when protocols are followed closely. For example, PCOS patients with no other complicating factors can often start letrozole under OB supervision. About 35% may conceive that way. The other 65% - especially those with poor or overly strong responses - need to be referred quickly. Those are the patients who benefit most from REI-level care.
In the long run, OB-GYNs need better training and standardization. Most OB-GYN residency programs only include 6–8 weeks of reproductive endocrinology - and it’s often the first rotation to get cut when staffing issues come up. That means many OBs aren’t confident managing fertility concerns, and some end up giving patients misinformation - like telling a 38-year-old to wait a year because “people get pregnant at that age all the time.”
Silvia
How do you see technology and automated triaging playing into this shift?
Dr. Ruben Alvero
Triaging is key. Patients with known fertility issues, advanced maternal age, or low ovarian reserve need to get referred to REIs without delay. Technology can help here - software that identifies red flags and recommends early referral can make a big difference.
I’m also a strong believer in protocols. In about 90% of cases, standardized protocols work extremely well. Individualized care is sometimes needed, but for the majority of patients, protocols ensure consistency and speed. If clinics and referring providers use technology to standardize assessments and triage early, we can handle more patients, more efficiently.
Silvia
What are the biggest opportunities and risks with California’s new mandate - and what can other states learn?
Dr. Ruben Alvero
California has a major opportunity to lead the way in equitable and accessible reproductive care. But there's also a real risk: if clinics aren’t able to scale quickly, patients may face long delays - even with coverage in place.
That’s why early preparation is critical. Clinics should be estimating their future patient volumes, hiring and training staff, strengthening referral networks, and investing in infrastructure now. Those who act early will be far better positioned than those who wait until the mandate fully takes effect in 2026.
For other states, the key takeaway is this: passing a mandate is just the beginning. The real challenge lies in execution - developing the workforce, educating providers, building efficient referral pathways, and ensuring the system can absorb higher demand. Without that groundwork, even the best policy can fall short in practice.
One more development we’re watching: we’ve submitted a proposal to include IVF coverage in the Affordable Care Act marketplace. It’s currently under federal review, and we hope to hear back later this year. If approved, it would mark another big step forward in expanding access to care.
Silvia
Thank you, we appreciate your time!