Josh Friedman , 2025-05-20 11:30:00
Key takeaways:
- Fertility preservation discussions should occur throughout the course of a patient’s care.
- Certain women with cancer may be able to freeze eggs or embryos after treatment.
Clinicians should discuss fertility preservation with patients both at cancer diagnosis and throughout survivorship, according to updated ASCO guidelines.
ASCO’s 2018 update highlighted the need to speak about fertility preservation as early in the process as possible, but care evolves over time, which necessitates renewed conversations, H. Irene Su, MD, MSCE, reproductive endocrinologist and professor of obstetrics, gynecology and reproductive sciences at UC San Diego Health, told Healio.
“This infertility risk discussion is a continuum, not just at the time of cancer treatment or cancer diagnosis, but also yearly post-treatment, as well as any time that a young patient with cancer is thinking about starting their family,” she said. “People’s goals change. Sometimes their cancer treatments change, and that prompts the necessity to readdress what is risk so that patients can consider their family building options and fertility preservation options.”
Concerns about infertility risk
Certain cancer treatments, including chemotherapy, radiation and surgery, have been shown to increase risk of infertility, according to study background.
Many individuals diagnosed with cancer have concerns about their infertility risk.
Healio previously reported on an investigation of women with breast cancer that showed 32% had concerns about fertility when they had to decide their treatment, and 47% reported fertility affected their treatment choice.
However, new data continue to be published regarding fertility possibilities.
“Fertility preservation options have expanded,” Su said. “We have more information about risk stratification in terms of what are the infertility risks of different types of cancer treatments.”
Additionally, 18 states and the District of Columbia have mandated state-regulated insurance cover fertility preservation since 2017, she added.
“I’m starting to see some of my young cancer survivors come back and try for their families,” Su said. “For many patients, they are able to complete their families without fertility preservation, but for so many more, we’re starting to use the sperm, the eggs, the embryos and the ovarian tissue we froze ahead of their cancer treatment. It’s amazing to have patients live long, healthy lives and have healthy babies to complete their family.”
Updates for women
A key addition to the updated guidelines involves offering fertility preservation to women following cancer treatment.
“There are going to be some patients who will have a much narrower window of ovarian function, meaning that they may become menopausal or infertile by the time that they are ready to start or complete their families,” Su said. “They may or may not have done appropriate or adequate fertility preservation prior to treatment, but if they have a narrowed window, we are suggesting that there’s consideration about whether to freeze eggs and freeze embryos in a post-treatment setting, as well.”
The authors also noted gonadotropin-releasing hormone agonists should not replace fertility preservation, but they can be used with it for breast cancer survivors.
Other updates include recommendations on novel and experimental fertility preservation methods such as in vitro maturation of eggs (may be offered; strength of recommendation, conditional) and uterine displacement (offered only in clinical trials/experimental protocols; conditional).
Clinicians should inform women of state laws, as well, so they can understand the risks of freezing embryos.
“Medically speaking, women who are freezing eggs vs. embryos should choose the best option for their situation in the moment,” Su said. “If there are potentially case laws or laws that limit the disposition of embryos, then I think they have to be super careful about where they freeze and where the embryos remain.”
Updates for men
Sperm freezing remains standard fertility preservation for men, but the guidelines now recommend they store multiple samples, if possible.
“If you freeze one sperm sample, the lab can aliquot it into a small number of tries in the future,” Su said. “But because every try for an insemination into the uterus has a relatively low likelihood of pregnancy per month, patients need a lot of samples. It’s better to freeze some vs. none, but if you’re able to, freezing up to three samples will give that family more options.”
Freezing testicular tissue for prepubertal males also could be an option.
“It’s experimental, but there’s lots of research going into the idea of freezing testicular tissue so that we can cryopreserve some of the stem cells in there,” Su said.
Su described that research as her “pie-in-the-sky” dream.
“How can you generate eggs and sperm from cells that are not egg cells and sperm cells to begin with?” she asked. “I don’t know when that will happen, but smart people are doing that.”
Future of fertility preservation
Su emphasized the need for research into fertility risks, specifically for newer treatments.
“Traditional chemotherapy kills cells indiscriminately,” Su said. “These new targeted therapies, if we can know early on that they have no fertility harm, the youngest of our patients would really like to know that so they don’t have to go through extra fertility preservation treatments prior to their cancer treatment.”
However, clinical trials often do not investigate fertility in early settings.
“Too often things like fertility or any other side effects are thought of in the future after a drug has been approved,” Su said. “We’re really advocating, from the time you’re developing a drug, to assess what the fertility risk is.”
Su remains optimistic for the future, though, and described the current state of fertility preservation as steadily improving.
“I think we’re going to have better laws for insurance coverage,” she said. “I think we’re going to have better implementation of those laws to reach more patients. I think that for highly resourced and less resourced settings, we’re going to see more patients getting care because research groups are coming up with tools [to address] how to deliver this care to every patient without having to reinvent the wheel. I think we’re going to get to testicular tissue transplantation for prepubertal males. I think we’re going to start seeing, hopefully, some births from using ovarian tissue from pre-pubertal females at the time that they were frozen.”
For more information:
H. Irene Su, MD, MSCE, can be reached at hisu@health.ucsd.edu.
Sources/Disclosures
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Disclosures:
Su reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
