This randomized controlled trial on 4 commercial grazing dairy farms investigated whether treatment with pegbovigrastim (PEG) affected fertility and culling as measured during the full lactation. We also explored the effect of potential interactions of PEG treatment with parity, prepartum body condition score, prepartum nonesterified fatty acid concentration (pre-NEFA), and early-lactation clinical disease on these outcomes. Holstein cows were randomly assigned to 1 of 2 trial arms: a first PEG dose approximately 7 d before the expected calving date and a second dose within 24 h after calving (PEG: primiparous = 342; multiparous = 697) compared with untreated controls (control: primiparous = 391; multiparous = 723). Cox’s proportional hazards regression models were used to analyze rate of first insemination, rate of pregnancy [within 150 and 305 d in milk (DIM)], and hazard of culling. Additional analyses were performed on data that were stratified by parity group and pre-NEFA class (low ≤0.3; high >0.3 mM). In high pre-NEFA cows, PEG treatment increased the rate of first insemination [hazard ratio (HR) = 1.15]. Early-lactation clinical mastitis (CM) and uterine disease (UD: retained placenta, metritis, or both) were associated with a reduced rate of pregnancy within 150 DIM (HR = 0.49 and 0.78, respectively). Pegbovigrastim treatment in high pre-NEFA cows with CM and UD increased the rate of pregnancy within 150 DIM (HR = 1.75 and 1.46, respectively). In high pre-NEFA cows, PEG treatment resulted in a lower hazard of culling (HR = 0.79). No treatment effect was detected in low pre-NEFA cows. This study shows that the effect of PEG treatment on fertility and culling interacts with pre-NEFA. In high pre-NEFA cows, PEG treatment increased the rate of first insemination, counteracted the negative association of early-lactation CM and UD with the rate of pregnancy, and decreased the hazard of culling.