Clinicians are advised to discuss reproductive risks and fertility preservation options with all cancer patients prior to initiating therapy to maximize future reproductive potential.
The American Society of Clinical Oncology (ASCO) released an updated clinical practice guideline in March 2025, providing evidence-based recommendations for fertility preservation in adult and pediatric patients diagnosed with cancer. In February 2026, a synopsis was published on JAMA on February 26, 2026, highlighting the guideline that incorporated data from 166 studies published between 2013 and 2024, from systematic reviews and randomized clinical trials. The guidance addresses the critical need for early intervention, as cancer treatments often carry gonadotoxic potential that can permanently impair reproductive function.1,2
This update reaffirmed the importance of discussing fertility preservation as an integral part of cancer care, ideally prior to the initiation of treatment. While much of the guidance reinforces established standards—such as sperm, oocyte, and embryo cryopreservation—the update reflects maturing evidence regarding newer techniques like ovarian tissue cryopreservation. The following FAQs summarize the major recommendations and clinical considerations for oncology and women’s health providers to support informed patient counseling, derived primarily from the synopsis published in JAMA, authored by Jayme Castillo, MD, Andrew M. Davis, MD, MPH, and Karen C. Burns, MD, MS.
1. When should clinicians initiate discussions regarding fertility preservation? Clinicians caring for adult and pediatric patients with cancer should discuss the possibility of infertility as early as possible before treatment starts (strong recommendation [SR]; moderate evidence quality [EQ]). Early discussion is vital because the window for successful gamete collection may close once chemotherapy or radiation therapy begins.
“For the first time, we’re formally recommending that cancer care providers clearly include fertility preservation in survivorship care. Here are ways to preserve fertility before and after cancer treatment, and we want to ensure that patients and clinicians are talking about the options throughout treatment, so that our patients can make informed decisions and have the best chance of meeting their goals in life.”
- Robin T. Zon, MD, FACP, FASCO, president, ASCO, via an ASCO press release about the guideline update, published in March 2025.2
2. What is the recommended method for male fertility preservation prior to treatment?
Cryopreservation of ejaculated sperm should be offered prior to initiating cancer-directed therapy (SR; high EQ). Data from a meta-analysis of 23,178 patients indicate that while only 9% (95% CI, 8%-10%) eventually use their samples, successful live births are achieved in 23% of cases using intracytoplasmic sperm injection.
3. What options exist for male patients who cannot provide an ejaculated semen sample?
Prior to cancer treatment, testicular sperm extraction (TESE) should be offered to pubertal/postpubertal males who cannot produce a semen sample (SR; high EQ). Surgical sperm retrieval via TESE has been shown to be successful in approximately 42.9% to 57.7% of patients when performed prior to cancer treatment.
4. Is embryo cryopreservation still considered a standard of care for female patients?
Yes. Embryo cryopreservation should be offered before cancer treatment begins (SR; high EQ). Meta-analyses of observational studies report clinical pregnancy rates of approximately 49.0% per total embryo transfer procedure.
5. Should oocyte cryopreservation be offered as an alternative to embryo banking?
Cryopreservation of unfertilized oocytes should be offered before treatment begins and may be well suited to females who prefer not to use partner or donor sperm or embryo cryopreservation (SR; high EQ). Live birth rates for pre-treatment oocyte cryopreservation range from 25.8% to 32% of transfer procedures.
6. Can fertility preservation be pursued after cancer treatment has already occurred?
Embryo and oocyte cryopreservation may be offered after cancer treatment for patients who did not undergo prior fertility preservation and who are at risk of primary ovarian insufficiency or infertility or lack sufficient cryopreserved tissue (SR; moderate EQ). However, clinicians should note that prior gonadotoxic treatment may lead to a lower yield of oocytes or embryos.
7. What is the status of ovarian tissue cryopreservation in the updated guidelines?
Ovarian tissue cryopreservation with a plan for future autologous transplant may be offered (SR; moderate EQ). Unlike oocyte retrieval, this method does not require hormonal stimulation and can be performed immediately, which is advantageous when cancer treatment cannot be delayed. Pooled clinical pregnancy rates are reported at 43.8% following transfer procedures.
8. What are the specific recommendations for pediatric and adolescent populations?
Clinicians should offer established methods of fertility preservation (eg, sperm or oocyte cryopreservation) for children and adolescents who have initiated puberty, with patient assent and parent or guardian consent (SR; moderate EQ). Additionally, those caring for adult and pediatric patients with cancer should discuss infertility as early as possible, prior to treatment.
9. Does ovarian stimulation for egg retrieval increase the risk of cancer recurrence in breast cancer patients?
Evidence suggests that aromatase inhibitor–based stimulation protocols do not increase the risk of recurrence. A meta-analysis of 4,643 patients with breast cancer found no increased risk of cancer recurrence or mortality compared to those who did not undergo ovarian stimulation.
10. What practical barriers should clinicians be prepared to discuss with patients?
Clinicians should counsel patients on the potential 2- to 3-week delay required for oocyte or embryo cryopreservation, as well as the costs and geographic limitations of fertility services. While insurance mandates for fertility preservation are increasing in the United States, access remains variable.
According to Zon, work still needs to be done regarding cost, as despite clear fertility risks posed with cancer treatment, insurers often consider fertility care not medically necessary, according to a statement from ASCO.
“Patients who may still want to have children following a cancer diagnosis are already facing difficult decisions about their care and futures,” said Zon. “These decisions should not be further complicated by financial barriers to evidence-based, medically necessary care.”2
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