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Published by American Society of Clinical Oncology · GRADE
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.
Key Takeaways
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.
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.
Clinicians should refer patients who express an interest in fertility preservation, and those who are uncertain, to reproductive specialists.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
In vitro maturation (IVM): IVM of oocytes may be offered as an emerging FP method.
Ovarian transposition: Ovarian transposition (oophoropexy) may be offered to reproductive-aged patients when pelvic irradiation is required.
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.
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.
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.
Ovarian suppression: For patients with oncologic emergencies requiring urgent chemotherapy, GnRHa may be offered and can provide benefits such as menstrual suppression.
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.
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.
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.
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.
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.
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.
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...
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
Therapeutic Area
OncologyGuideline Scope
Inclusion Criteria
Care Settings
Special Populations
System: GRADE
Evidence Levels
Recommendation Strength
Contraindications
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.
Difficulty
advanced
Learning Paths