Introduction/Background: Medical treatments received by transgender and/or gender diverse (TGD) people can impact fertility, yet the literature lacks data on factors that influence fertility decisions among TGD people. Specific Aim(s): This study aimed to identify predictors of interest in fertility preservation (IFP). Materials and Methods: This retrospective observational study utilized data from 2021–2023 from an adult gender registry for patients receiving care at academic medical center (n = 206). Patient demographic data and survey responses to questions about fertility were queried and analyzed. Bivariate and multivariate analyses were conducted using logistic regression. Results: Most patients (73.8%, n = 152) were not interested in fertility preservation (FP) and 16.5% (n = 34) were unsure. Reasons most often cited were not wanting biological children (55.9%, n = 104), preferring adoption (20.4%, n = 38), cost (19.9%, n = 37), and dysphoria (19.4%, n = 36). Bivariate analyses showed that increasing age, being married, and already having children were significantly inversely associated with IFP (p = 0.03, 0.01, 0.02, respectively). Non-Hispanic Black race/ethnicity (OR (95% CI): 3.43 (1.19, 9.84)) and disability or unemployment (OR (95% CI): 4.19 (1.42, 13.00)) were significantly associated with IFP vs. Non-Hispanic White race/ethnicity and full-time employment, respectively. In multivariate models, being married was significantly inversely associated with IFP, e.g., OR (95% CI): 0.30, (0.07, 0.99), when accounting for age and already having children. Race/ethnicity and employment comparisons remained significant after adjusting for other factors. Conclusions: Most patients did not desire FP. Among those IFP, potential predictors include age, marital status, already having children, race and ethnicity, and employment and disability status.