Each year in the United States, about 90,000 adolescents and young adults (AYAs), ages 15 to 39, are diagnosed with cancer,¹ and they are immediately faced with myriad challenges and disruptions in their life stages, including psychosocial distress; interruptions in their education, career, and social life; body image struggles; and potentially life-altering consequences on fertility. Studies show that between 12% and 88% of AYAs undergoing treatment for cancer, including surgery, chemotherapy, and radiation therapy, experience risk to their fertility.² 

Despite these alarming statistics, a recent study evaluating fertility preservation patterns found that only half of patients of reproductive age at the time of their cancer diagnosis reported having a discussion about their fertility preservation options with their health-care provider.³ The results are contrary to the recommendations outlined in ASCO’s Fertility Preservation for Patients With Cancer Practice Guideline Update, issued in 2018.³ The guideline recommends that all providers, including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, and surgeons, address the potential risk of infertility with their young patients and offer options and/or referrals to reproductive specialists for counseling as early as possible before cancer treatment begins.

“The hope is that these new guidelines are paired with quality oncology practice metrics in fertility screening. ASCO has put together a task force to reimagine how we measure whether oncology practices are delivering oncofertility care. We will be developing tools to help oncology practices routinely screen for this care at diagnosis and throughout survivorship care.”

— H. IRENE SU, MD, MSCE

Tweet this quote

In March 2025, ASCO issued an updated clinical practice guideline on fertility preservation for individuals with cancer, which for the first time recommends that oncology providers offer fertility preservation approaches in survivorship care after cancer treatment ends, in addition to offering counseling on the issue at diagnosis.⁴ The updated guideline also highlights emerging and experimental methods of fertility preservation, including in vitro maturation of eggs as an emerging method of fertility preservation for some young patients with cancer.

In a wide-ranging interview with The ASCO Post, lead author of ASCO’s new guideline, H. Irene Su, MD, MSCE, Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences; Co-Director, Center for Obstetrics and Gynecology Research Innovations; and Director, Moores Cancer Center Leadership Academy, discussed the importance of initiating fertility preservation conversations at different time points throughout survivorship, including after active cancer treatment is completed; how cancer and its treatment put fertility at risk; new approaches to protect fertility; and the cost barriers to receiving this care.

Maintaining Oncofertility Discussions Throughout Survivorship

Please talk about the significance of ASCO’s updated clinical practice guideline on fertility preservation, which calls for counseling both at diagnosis and in survivorship after cancer treatment ends. 

There are many time points in a young cancer survivor’s journey during which having an oncofertility discussion would be helpful in their care. The first is, of course, at diagnosis. In the updated guideline we also included a reminder of the importance of having this discussion posttreatment as well, because patients may not have fully processed the information about the treatment-related risk to their fertility at diagnosis, so it’s important to raise the issue throughout survivorship to help ensure that an individual’s reproductive potential is preserved when possible.

This is especially important for some female patients who may have a smaller remaining window for fertility preservation posttreatment, and it’s important for them to know about that window. For younger female patients, who only have a finite number of eggs, the primary risk is their treatment protocol because chemotherapy and radiation can severely damage the ovaries, killing eggs, and causing premature menopause or infertility. For older women, the threshold for losing their eggs to the point of infertility is much less than it is for younger women. 

Helping Patients Make Informed Decisions About Their Fertility Care

How will ASCO’s updated guideline help increase the number of routine fertility preservation conversations after a cancer diagnosis?

This is a real concern because we want our patients to be able to make informed decisions about their care, including fertility preservation, so we can give them the best opportunity to meet their life goals. One problem is that these conversations are not happening consistently at diagnosis. Another issue is that even when patients are informed about treatment-related fertility risks, they may be ambivalent about undergoing fertility preservation if it delays their cancer treatment.

Another big barrier is even if these young patients want to pursue fertility preservation, they may not be able to afford it if their health insurance doesn’t cover the procedures. So, there are multiple levels of barriers to increasing the rates of fertility preservation.

The hope is that these new guidelines are paired with quality oncology practice metrics in fertility screening. ASCO has put together a task force to reimagine how we measure whether oncology practices are delivering oncofertility care. We will be developing tools to help oncology practices routinely screen for this care at diagnosis and throughout survivorship care. For example, we have a clinical trial that is investigating how electronic health records can incorporate screening alerts to refer patients to fertility counseling to ensure that more patients get referred for this care.

Increasing Fertility Preservation

What is the success rate for fertility preservation for young cancer survivors; and are there some types of cancer or cancer treatment that increase the risk of infertility?

The success rate of fertility preservation varies depending on the type of services used. For example, the majority of male patients who freeze their sperm prior to cancer treatment will be successful in conceiving with a female partner. Egg and embryo freezing can also provide a high rate of conception depending on the number and quality of the eggs and embryos when they are frozen.

Fortunately, most young cancer survivors do not have infertility when they are diagnosed, so the chances that their fertility can be preserved are good.Overall, the estimate is that for every embryo that we transfer back to the patient after treatment, the expectation of conceiving and having a live birth is between 40% and 60%.

In terms of the risks of infertility from cancer treatment, we know that alkylating agents and platinum-based chemotherapies and large doses of radiation therapy to the pelvis that hits the ovaries, the uterus, or the testes increase the risk of infertility. We are also concerned about how targeted therapies affect the reproductive system, and we don’t have the answer to that question yet.

In the longer-term, scientists and industry partners need to take fertility outcomes into account in their development of new drugs.

Improving Reproductive Outcomes 

What progress has been made in improving methods of fertility preservation?

For females, egg freezing or embryo freezing have improved to the point that there is a high likelihood of conception and a live birth from these methods. The newer method of in vitro maturation, in which oocytes are retrieved from the ovaries with minimal hormonal stimulation and matured to a fertilizable state in a laboratory, is improving and holds promise for the future.

There are also new surgical approaches for patients receiving radiation therapy to the pelvic area, including uterine transposition, which involves moving the uterus and ovaries to the upper abdomen to shield them from the treatment.

For male patients, sperm cryopreservation, which has a nearly 95% success rate, is the most established and widely accepted method of fertility preservation. Research is also underway on preserving the fertility of prepubertal boys through testicular tissue banking.

Implementing Timely Referral to a Reproductive Specialist

What is the major concern about attempting to preserve fertility at diagnosis; that it may delay the start of cancer treatment?

Time is of the essence when considering fertility preservation options after a cancer diagnosis. For males, sperm banking can be done quickly, and a collection of sperm can be done multiple times to retrieve the desired number of samples.

For females, fertility preservation may take 2 to 3 weeks for established techniques that involve the collection of eggs (either egg or embryo freezing). However, some other emerging approaches, such as in vitro maturation of oocytes and novel pharmacological interventions to preserve ovarian function, may be possible to implement sooner, so timely referral to a reproductive specialist is crucial.

Covering the High Costs of Oncofertility Care

Fertility preservation can cost thousands of dollars, which is usually not covered by health insurance, making it out of reach for many young cancer survivors. Please talk about the financial barriers to receiving this care.

The good news is that 21 states and the District of Columbia now have insurance mandates in place to cover oncofertility preservation, which means that patients with cancer in those states could potentially be covered for that care, although they still may incur costs through deductibles and coinsurance. And most other states are considering passing similar mandates.

GUEST EDITOR

Brandon Hayes-Lattin, MD, FACP

Brandon Hayes-Lattin, MD, FACP, is Professor of Medicine and Deputy Division Head of Hematology and Medical Oncology at Oregon Health and Science University, and Medical Director of the Adolescent and Young Adult Oncology Program at the Knight Cancer Institute at Oregon Health and Science University, Portland, Oregon.

However, those mandates largely exclude publicly insured individuals, so only a handful of Medicaid patients with cancer are eligible to receive this benefit. And the laws are written differently by individual states, with each state offering various levels of coverage or no coverage at all depending on the type of cancer, so significant gaps in care remain.

Discussions of cost can be an important part of clinician and patient shared decision-making. It’s important for clinicians to learn about their state’s law on fertility preservation insurance coverage to counsel patients on what services might be covered, and refer patients to financial counseling services available at their institution to help defray potential costs. 

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.