Prognia
Back to Guidelines
American Society of Clinical OncologyMedical Oncology2025advanced

Fertility Preservation in Patients With Cancer

Published by American Society of Clinical Oncology · GRADE

26Recommendations
240References
5Tables
1Figures
Read Full Guideline

Summary

AI-generated

Many cancer-directed therapies, including chemotherapy, radiation, and surgery, pose a risk to reproductive health, making it critical to address fertility concerns as early as possible. This guideline provides a comprehensive approach to assessing, discussing, and offering evidence-based fertility preservation options to adult, adolescent, and pediatric cancer patients to ensure reproductive potential is preserved whenever possible.

fertility preservationcancerASCOmedical oncologysperm cryopreservationembryo cryopreservationoocyte cryopreservationovarian tissue cryopreservation

Key Takeaways

  • 1
    Patients should be counseled about reproductive risks at diagnosis and during survivorship.
  • 2
    Sperm cryopreservation is the established FP method for males and should be offered prior to cancer treatment.
  • 3
    Embryo, oocyte, and ovarian tissue cryopreservation are established FP methods for females.
  • 4
    Gonadotropin-releasing hormone agonists (GnRHa) should not replace established FP methods but may be used as an adjunct in breast cancer or for menstrual suppression in oncologic emergencies.
  • 5
    Ovarian tissue cryopreservation is the only established method for prepubertal females.
  • 6
    Prompt access to a multidisciplinary fertility preservation team is essential.

What's New in This Version

Update to the 2018 ASCO clinical practice guideline. Reflects literature review from 2013 through September 2024, expanding guidance on in vitro maturation, post-treatment FP settings, ovarian tissue cryopreservation in prepubertal patients, and adding detailed algorithms.

Key Recommendations

Discussing risk of infertility with patient

  • 1.1

    Clinicians caring for adult and pediatric patients with cancer should discuss the possibility of infertility as early as possible before treatment starts to preserve the full range of options.

    StrongEvidence: ModerateCounseling
  • 1.2

    Clinicians should refer patients who express an interest in fertility preservation, and those who are uncertain, to reproductive specialists.

    StrongEvidence: Very lowCounseling
  • 1.3

    Clinicians should initiate the discussion regarding infertility with the knowledge that it can ultimately reduce distress and improve quality of life, even if the patient does not undergo fertility preservation.

    StrongEvidence: ModerateCounseling
  • 1.4

    Additional discussions and/or referrals may be offered yearly when the patient returns for follow-up after completion of cancer-directed therapy or when treatment plans change or evolve, as well as if pregnancy is being considered. The discussions should be ongoing throughout survivorship and documented in the medical record.

    StrongEvidence: LowCounseling

Risks of infertility from cancer treatment

  • 2.1

    Clinicians should offer an evaluation and counseling regarding the risk of reproductive function impairment and infertility to ensure that all patients are appropriately informed and supported in managing the potential reproductive impacts of their cancer treatment.

    StrongEvidence: ModerateScreening

Fertility preservation in males

  • 3.1

    Sperm cryopreservation: Cryopreservation of ejaculated sperm (sperm banking) should be offered prior to initiating cancer-directed therapy. Health care clinicians should discuss sperm banking with all pubertal and postpubertal males prior to receiving cancer treatment.

    StrongEvidence: HighTreatment
  • 3.2

    Testicular sperm extraction (TESE): TESE with sperm cryopreservation should be offered to pubertal and post-pubertal males who cannot produce a semen sample, before cancer treatment begins.

    StrongEvidence: HighTreatment
  • 3.3

    Hormonal gonadoprotection: Hormonal suppression therapy should not be offered to males as an approach for preserving fertility. It is not effective and therefore not recommended.

    StrongEvidence: HighTreatment
  • 3.4

    Other methods to preserve male fertility: Other methods, such as testicular tissue cryopreservation in pre-pubertal males and reimplantation or grafting of human testicular tissue, should be performed only as part of clinical trials or approved experimental protocols.

    StrongEvidence: Very lowTreatment
  • 3.5

    Post-treatment setting: Males should be advised of a potentially higher risk of genetic damage in sperm collected soon after initiation and completion of antineoplastic and/or radiation therapy. It is strongly recommended that sperm be collected before initiation of treatment because the quality of the sample and sperm DNA integrity may be compromised after a single treatment.

    StrongEvidence: LowCounseling

Fertility preservation in females

  • 4.1

    Embryo cryopreservation: Embryo cryopreservation should be offered as it is an established fertility preservation method, and it has routinely been used for storing embryos after in vitro fertilization.

    StrongEvidence: HighTreatment
  • 4.2

    Mature oocyte cryopreservation: Cryopreservation of unfertilized oocytes should be offered as it is an established fertility preservation method and may be especially well suited to females who do not have a male partner, do not wish to use donor sperm, or have religious or ethical objections to embryo freezing.

    StrongEvidence: HighTreatment
  • 4.3

    Post-treatment setting: Embryo and oocyte cryopreservation for fertility preservation may be offered in the post-treatment setting to patients who did not undergo fertility preservation before their cancer treatment but are at risk of primary ovarian insufficiency or infertility.

    StrongEvidence: ModerateTreatment
  • 4.4

    In vitro maturation (IVM): IVM of oocytes may be offered as an emerging FP method.

    ConditionalEvidence: LowTreatment
  • 4.5

    Ovarian transposition: Ovarian transposition (oophoropexy) may be offered to reproductive-aged patients when pelvic irradiation is required.

    StrongEvidence: ModerateTreatment
  • 4.6

    Uterine transposition: Uterine transposition in reproductive-aged patients remains experimental and should be offered only as part of a clinical trial or approved experimental protocols.

    ConditionalEvidence: LowTreatment
  • 4.7

    Conservative gynecologic surgery: a. For patients with stage IA2 to IB1 cervical cancer, radical trachelectomy may be offered to preserve fertility... b. For patients with well-differentiated (grade 1) endometrial tumors with minimal myometrial invasion... fertility-sparing surgery may be offered. c. Patients with stage IA grade 1 epithelial ovarian cancer after thorough staging may be offered fertility-sparing surgery. d. In other gynecologic malignancies, less radical surgeries may be offered to spare reproductive organs when clinically appropriate.

    StrongEvidence: ModerateTreatment
  • 4.8

    Ovarian suppression: Gonadotropin-releasing hormone agonists (GnRHa) should not be used in place of established fertility preservation methods such as oocyte, embryo, or ovarian tissue cryopreservation. GnRHa may be offered as an adjunct to females with breast cancer.

    ConditionalEvidence: ModerateTreatment
  • 4.9

    Ovarian suppression: For patients with oncologic emergencies requiring urgent chemotherapy, GnRHa may be offered and can provide benefits such as menstrual suppression.

    ConditionalEvidence: LowTreatment
  • 4.10

    Ovarian tissue cryopreservation and transplantation: Ovarian tissue cryopreservation (OTC) for the purpose of future transplantation may be offered to patients with cancer as an established fertility preservation method. As it does not require ovarian stimulation, it can be performed immediately in those unable to delay chemotherapy.

    StrongEvidence: ModerateTreatment

Fertility preservation in children

  • 5.1

    Clinicians should offer established methods of fertility preservation (eg, semen or oocyte cryopreservation) in children and adolescents who have initiated puberty, with patient assent and parent or guardian consent. For prepubertal children, the only fertility preservation options are ovarian and testicular cryopreservation, the latter of which is currently investigational.

    StrongEvidence: ModerateTreatment

Role of clinicians

  • 6.1

    All clinicians should be prepared to discuss infertility as a potential risk of therapy. This discussion should take place as soon as possible once a cancer diagnosis is made and can occur simultaneously with staging and the formulation of a treatment plan.

    StrongEvidence: Very lowCounseling
  • 6.2

    All clinicians should encourage patients to participate in registries and clinical studies, as available, to define further the gonadotoxic risks of cancer-directed therapies as well as the safety and efficacy of fertility preservation interventions and strategies.

    Good Practice StatementManagement
  • 6.3

    All clinicians should refer patients who express an interest in fertility, as well as those who are ambivalent or uncertain, to reproductive specialists as soon as possible.

    Good Practice StatementCounseling
  • 6.4

    Oncology teams should identify and ensure prompt access to a multidisciplinary fertility preservation team including fertility specialists, trained mental-health professionals for emotional support and guidance on family building decision-making, social workers, financial counseling and insurance navigation, and genetic counselors.

    Good Practice StatementManagement
  • 6.5

    Health insurance benefit mandates and benefits for fertility preservation should specify comprehensive coverage of guideline-based fertility preservation services and long-term storage, parity with other insurance benefits, and elimination of prior authorization. Clinicians should advocate for comprehensive insurance coverage of fertility preservation services...

    Good Practice StatementManagement

Scope & Objectives

Clinical Topic

Fertility Preservation

Objectives

To provide updated fertility preservation (FP) recommendations for people with cancer.

Target Patient Population

People with cancer who are at risk of infertility due to cancer-directed treatment.

Target Providers

Medical oncologistsRadiation oncologistsGynecologic oncologistsUrologistsHematologistsPediatric oncologistsAdvanced practice professionalsSurgeonsNursesSocial workersPsychologists

Patient Criteria & Setting

Therapeutic Area

Oncology

Guideline Scope

CounselingScreeningManagementTreatment

Inclusion Criteria

  • People who are to undergo or have completed cancer-directed treatments that threaten fertility
  • Prepubertal patients with cancer

Care Settings

Oncology practicesFertility preservation centersMultidisciplinary cancer care centers

Special Populations

Prepubertal childrenAdolescentsPatients with oncologic emergenciesPatients with breast cancerPatients with estrogen-sensitive malignancies

Evidence Grading

System: GRADE

Evidence Levels

LowOur confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
HighWe are very confident that the true effect lies close to that of the estimate of the effect.
ModerateWe are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Very lowWe have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Recommendation Strength

StrongIn recommendations for an intervention, the desirable effects of an intervention outweigh its undesirable effects. All or almost all informed people would make the recommended choice for or against an intervention.
Conditional/weakIn recommendations for an intervention, the desirable effects probably outweigh the undesirable effects, but appreciable uncertainty exists. Most informed people would choose the recommended course of action, but a substantial number would not.

Safety & Contraindications

Contraindications

  • Hormonal suppression therapy should not be offered to males to preserve fertility.
  • Gonadotropin-releasing hormone agonist (GnRHa) should not be used in place of established fertility preservation methods.

Monitoring Guidance

Ongoing fertility discussions and referrals may be offered yearly when patients return for follow-up, when treatment plans change, or if pregnancy is considered.

Authors & Contributors

H. Irene SuChristina LacchettiJoseph LetourneauAnn H. PartridgeRubina QamarGwendolyn P. QuinnJoyce ReineckeJames F. SmithMegan TeschW. Hamish WallaceErica T. WangAlison W. Loren

Guideline Features

Flowcharts includedBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

OncologyFertility PreservationOncofertilityCryopreservationCancer SurvivorshipGynecologic OncologyPediatric Oncology