ASCO Updates Fertility Preservation Guidelines for Young Cancer Patients
The landscape of cancer care is evolving, and with it, a growing emphasis on preserving quality of life beyond treatment – including reproductive health. For adolescents and young adults (AYAs), aged 15 to 39, facing a cancer diagnosis, the potential impact on fertility is a significant concern. Approximately 90,000 AYAs in the United States receive a cancer diagnosis each year, and studies indicate that between 12% and 88% may experience risks to their fertility due to surgery, chemotherapy, and radiation therapy.1 However, recent updates to clinical practice guidelines from organizations like the American Society of Clinical Oncology (ASCO) signal a shift towards more proactive and comprehensive oncofertility care, extending beyond diagnosis and into survivorship.
Addressing a Gap in Communication
Despite the known risks and established recommendations, a concerning gap exists between awareness and action. A recent study revealed that only half of patients of reproductive age discussed fertility preservation options with their healthcare provider at the time of their cancer diagnosis.2 This finding underscores the need for improved communication and systematic integration of oncofertility discussions into standard cancer care protocols. ASCO’s 2018 practice guideline recommended that all oncology providers – medical, radiation, gynecologic, urologists, hematologists, pediatric oncologists, and surgeons – address potential infertility risks and offer referrals to reproductive specialists.
Expanding the Timeline for Fertility Discussions
Recognizing the need for a more holistic approach, ASCO issued an updated clinical practice guideline in March 2025, broadening the scope of fertility preservation counseling.4 For the first time, the guideline recommends offering fertility preservation approaches not only at diagnosis but similarly during survivorship, after active cancer treatment concludes. This acknowledges that patients may need time to process information and that reproductive potential may change post-treatment. The updated guideline also highlights emerging methods like in vitro maturation (IVM) of eggs as a potential option for some young patients.
Understanding the Risks and Emerging Approaches
Cancer and its treatment can jeopardize fertility through various mechanisms. Chemotherapy and radiation can severely damage the ovaries, leading to premature menopause or infertility in women, as they have a finite number of eggs. For men, treatments can affect sperm production. Alkylating agents and platinum-based chemotherapies, along with high doses of radiation to the pelvic area, pose significant risks.1 Researchers are also investigating the potential impact of targeted therapies on the reproductive system, an area where more data is needed.
Fortunately, the majority of young cancer survivors do not experience infertility at diagnosis, suggesting a good chance of preserving fertility. Success rates for preservation techniques vary. Sperm banking for male patients boasts a nearly 95% success rate. Egg and embryo freezing can also yield high conception rates, depending on the quality and quantity of eggs or embryos frozen, with an estimated 40-60% chance of a live birth per embryo transfer.1 IVM, a newer technique, involves retrieving immature eggs and maturing them in a laboratory setting, offering promise for patients who may not have time for traditional stimulation protocols.
Beyond Diagnosis: Maintaining the Conversation Through Survivorship
H. Irene Su, MD, MSCE, Professor at Oregon Health & Science University and lead author of ASCO’s novel guideline, emphasizes the importance of ongoing oncofertility discussions. “There are many time points in a young cancer survivor’s journey during which having an oncofertility discussion would be helpful,” she explains.1 Post-treatment discussions are crucial, as patients may not have fully grasped the implications of treatment on their fertility during the initial shock of diagnosis. For younger women, understanding the limited number of eggs remaining is particularly important when making decisions about fertility preservation.
Addressing Barriers to Access
While guidelines are essential, translating them into practice requires addressing significant barriers. One major hurdle is simply ensuring that fertility preservation conversations happen consistently at diagnosis. Even when patients are informed, they may be hesitant if it delays cancer treatment. Perhaps the most substantial barrier is cost. Fertility preservation procedures can be expensive, and insurance coverage is often limited.
Currently, 21 states and the District of Columbia have insurance mandates covering oncofertility preservation, but coverage varies significantly. Many mandates exclude individuals with public insurance (Medicaid), leaving a gap in access for vulnerable populations.1 Clinicians are encouraged to stay informed about their state’s laws and connect patients with financial counseling services to help offset costs.
Measuring Progress and Improving Care Delivery
ASCO is actively working to improve the delivery of oncofertility care through quality oncology practice metrics. A task force has been established to develop tools for routinely screening patients for fertility risks at diagnosis and throughout survivorship. One initiative involves integrating screening alerts into electronic health records to prompt referrals to reproductive specialists.1
Surgical Approaches to Protect Fertility
Beyond preservation techniques, surgical approaches are also evolving. Uterine transposition, a procedure involving moving the uterus and ovaries to shield them from radiation, is being utilized in certain cases.1
The Future of Oncofertility
The field of oncofertility is dynamic, with ongoing research focused on improving existing techniques and developing new ones. Scientists and industry partners are increasingly recognizing the importance of incorporating fertility outcomes into the development of new cancer drugs. As our understanding of the reproductive system and cancer treatment evolves, the outlook for fertility preservation in patients with cancer continues to improve.
For more information on cancer in adolescents and young adults, visit the National Cancer Institute’s website. You can also find resources and support from the American Cancer Society. It is crucial to discuss your individual situation and concerns with a qualified healthcare professional.
DISCLOSURE: Dr. Su has no conflicts of interest to declare.
REFERENCES
1. American Cancer Society: Special Section: Cancer in Adolescents and Young Adults. Available at www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/special-section-cancer-in-adolescents-and-young-adults-2020.pdf.
2. Appiah LC, Fei YF, Olsen M, et al: Disparities in female pediatric, adolescent and young adult oncofertility: a needs assessment. Cancers (Basel) 13(21):5419, 2021.
3. Oktay K, Harvey BE, Partridge AH, et al: Fertility preservation in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol 36:1994-2001, 2018.
4. Su HI, Lacchetti C, Letourneau J, et al: Fertility preservation in people with cancer: ASCO guideline. J Clin Oncol 43(12):1488-1515, 2025.