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The American Society of Clinical Oncology (ASCO) has released updated guidelines to guide fertility preservation for people with cancer, with the previous update published in 2018.

The 2025 update reflects substantial growth in the evidence base, with 166 studies incorporated compared with just 61 studies in the 2018 guidelines. According to the authors, this expanded evidence has allowed for more detailed recommendations and has broadened the scope to address the needs of diverse patient populations.

Why Update the Guidelines, and Why Now?

Although the importance of fertility preservation is widely recognized, there is a need for up-to-date evidence-based guidance for healthcare clinicians caring for adults with cancer. The authors of the guidelines noted that patients often do not receive adequate information regarding fertility preservation before starting cancer therapy.

“We updated the guideline because of new discoveries in how to deliver fertility preservation care, the expansion of effective fertility preservation treatments, and recent changes in insurance coverage of these services,” explained H. Irene Su, MD, MSCE, co-chair of the Expert Panel that developed the 2025 guidelines.

The update comes at a critical time, according to Mahmoud Salama, MD, PhD, director of the Oncofertility Consortium at Michigan State University, East Lansing, Michigan, who was not involved in the development of the updated guidelines.

“As the numbers of young cancer patients surviving into adulthood have increased due to advances in early diagnosis and treatment, long-term health issues, such as fertility, have gained growing attention,” Salama said.

What Are the Most Significant Changes?

The 2025 guidelines maintain the recommendation of the 2018 guidelines that healthcare providers should discuss fertility preservation with all reproductive-age patients as early as possible before cancer treatment begins. However, the updated recommendations also include posttreatment fertility discussions. The guidelines now recommend yearly fertility discussions after treatment, when cancer treatments change, or when pregnancy is being considered.

“This is because cancer survivors’ family-building decisions change over time, and they do not always remember the initial counseling; posttreatment counseling can reduce distress and improve quality of life, even if the patient does not undergo fertility preservation per se,” Su reasoned.

She added that now, there are more data to inform infertility risk stratification, and patients at high risk can seriously consider fertility preservation to expand their family-building options, whereas patients at low risk do not need to undergo additional procedures before cancer treatments.

In addition to posttreatment fertility discussions, the updated guidelines also recommend offering oocyte and embryo freezing for fertility preservation posttreatment to individuals who are at risk for primary ovarian insufficiency but still have a viable ovarian reserve. Recommendations for posttreatment fertility preservation were not included in the 2018 guidelines. Su acknowledged, however, that the timing of attempting posttreatment fertility preservation is still unclear, “with some data suggesting an optimal number of oocytes 2-3 years after the end of treatment.”

What About Ovarian Suppression?

The 2025 ASCO guidelines provide detailed recommendations regarding the use of gonadotropin-releasing hormone agonists (GnRHa).

Although the 2018 guideline noted “conflicting evidence” for the use of GnRHa and other means of ovarian suppression for fertility preservation, the 2025 update maintains that GnRHa should not be used in place of established fertility preservation methods, such as oocyte, embryo, or ovarian tissue cryopreservation but may be offered as an adjunct to patients with breast cancer.

Additionally, the 2025 guidelines introduced a new recommendation that GnRHa may be offered for menstrual suppression in patients with oncologic emergencies requiring urgent chemotherapy, something that was not addressed in the 2018 guidelines.

How Will These Changes Affect Clinical Practice?

The 2025 guidelines emphasize the importance of a multidisciplinary approach, recommending that oncology teams should ensure prompt access to a multidisciplinary fertility preservation team. The team should include fertility specialists, mental health professionals, social workers, financial counselors, and genetic counselors.

This recommendation represents an expansion from the 2018 guidelines, which recommended referring patients to reproductive specialists and psychosocial providers when they are distressed about potential infertility.

In addition, the 2025 guidelines advocate for insurance coverage, reflecting the growing recognition that financial barriers often prevent patients from accessing fertility preservation services. Su explained that, for the first time, ASCO has included a policy recommendation in a clinical guideline. This recommendation addresses insurance coverage “in response to a lot of variation in laws that mandate fertility preservation insurance coverage across 18 states and DC.” According to the updated guidelines, these mandates should specify comprehensive coverage of guideline-based fertility preservation services and long-term storage, parity with other insurance benefits, and elimination of prior authorization.

What Are Other Organizations’ Fertility Preservation Guidelines?

The updated ASCO guidelines join a growing international consensus on the importance of fertility preservation for patients with cancer, Salama said.

“A growing recognition of the importance of fertility preservation for patients with cancer is underscored worldwide by the numerous international fertility preservation and restoration guidelines that have been published over the past 20 years,” he added.

Organizations publishing fertility preservation guidance documents and resources include the American Society for Reproductive Medicine, the European Society of Human Reproduction and Embryology, the European Society for Medical Oncology, the Oncofertility Consortium, the International Society for Fertility Preservation, and the American Academy of Pediatrics.

Recommendations and guidelines from these associations and societies “have highlighted the recent developments in the field and how these developments can be translated from bench to bedside,” Salama said.

What Barriers Exist to Following Fertility Preservation Guidelines?

Su acknowledged that time constraints may hinder the implementation of fertility preservation guidelines.

“Oncology teams are incredibly busy and need to identify a pathway for every patient to be screened for reproductive health needs and have a warm handoff to and return from fertility specialists,” she said. Spending time to identify this pathway and resources, much of which may be delivered remotely, will make the process more feasible, even in resource-limited settings, Su added.

Salama identified additional potential barriers to guideline implementation: “Challenges in implementation include lack of experienced teams and necessary equipment, lack of awareness among providers and patients, and lack of insurance coverage or financial support resulting in high out-of-pocket costs for patients.”

He added that, to provide fertility preservation and restoration strategies to young patients with cancer, “the treating center should be properly equipped, with a highly skilled multidisciplinary team of oncologists, reproductive medicine specialists, gynecologists, andrologists, reproductive biologists, transplantation surgeons, patient navigators, and research scientists.”

Outlook

Commenting on the clinical impact of these guidelines, Su said, “We hope cancer survivors can engage in regular discussions about their reproductive health throughout the cancer care continuum, starting at diagnosis, and make informed decisions about fertility and contraception.”

Salama emphasized that personalization is key to helping patients with cancer achieve their family-building goals, noting that “fertility preservation and restoration strategies should be tailored to each patient’s circumstances and wishes and may involve a combination of established, debatable, and experimental options.”

He added that early referral and counseling can help clinicians and patient navigators better support patients in making informed decisions about fertility preservation, particularly in time-sensitive or high-stress situations.

All funding for the administration of the guideline development project was provided by ASCO. Su and Salama reported no relevant financial relationships.

Christos Evangelou, PhD, is a freelance medical writer and science communications consultant.