Fertility Preservation in Cancer Care Matters More Than Ever: What Does the 2025 Guideline Add?

Why Is Fertility Preservation More Important Now?

Modern oncology aims to treat disease while safeguarding patients' quality of life afterward. Loss of fertility, the ability to reproduce, is therefore a critical concern for people diagnosed with cancer during their reproductive years, directly affecting quality of life and future plans. Millions of young adults and children receive cancer treatment each year, and their hopes of having children later may sometimes be irreversibly damaged.

Recognizing its importance, the American Society of Clinical Oncology (ASCO) took its guideline published in 2018 and updated its fertility preservation recommendations in 2025. The update considers new treatment options alongside patients' changing needs.

What Does the New Guideline Add?

ASCO's 2025 guideline is a substantial update to the 2018 version. Whereas the previous guideline cited only 61 scientific studies, the new one includes 166. This increase has enabled more detailed recommendations and better attention to the needs of different patient groups.

The Key Update: Fertility Discussions Are No Longer a One-Time Conversation

As before, discussion of fertility before treatment is recommended for all patients of reproductive age. However, the new guideline emphasizes that discussion only at diagnosis is insufficient. Fertility conversations should now be revisited at annual follow-ups, when treatment plans change, or when a patient is considering pregnancy.

Post-Treatment Fertility Preservation Recommendations Included for the First Time

This is one of the most notable additions to the 2025 guideline. After treatment, egg (oocyte) and embryo freezing may be offered to individuals who retain adequate ovarian reserve but are at risk of primary ovarian insufficiency. This recommendation was not included in the 2018 guideline.

However, there is no clear consensus on the ideal timing of post-treatment fertility preservation. Some studies suggest that the best time for egg retrieval may be 2-3 years after treatment.

What Is the Role of GnRH Agonists?

Gonadotropin-releasing hormone agonists (GnRHa) may be recommended for menstrual suppression, particularly when urgent chemotherapy is needed. However, evidence remains insufficiently strong to support GnRHa alone for fertility preservation. They can therefore be used only as an addition to established methods such as embryo, oocyte, or ovarian tissue freezing.

A Multidisciplinary Approach Is Recommended

The new guideline emphasizes that fertility preservation services should extend beyond oncologists. It recommends involving a team of fertility specialists, psychologists, social workers, genetic counselors, and financial counselors. This approach aims to improve patients' experience through both information and emotional support.

Financial Access and Insurance Coverage Now Included

For the first time, ASCO has included a policy recommendation in a clinical guideline. Fertility preservation still requires out-of-pocket payment in many countries, limiting access. The 2025 guideline recommends comprehensive insurance coverage for these services. In the United States, 18 states and DC support them, but coverage and standards vary considerably.

History of Fertility Preservation in Cancer

Scientific investigation of cancer treatment's effects on fertility began in the 1980s. In the early 2000s, initiatives such as the Oncofertility Consortium developed clinical and ethical guidance. ASCO published its first formal fertility preservation guideline in 2006. This was followed by:

• 2007: American Society for Reproductive Medicine (ASRM) guidelines

• 2013: European Society of Human Reproduction and Embryology (ESHRE)

• 2018: ASCO's previous guideline

• After 2020: Recommendations also came from organizations such as the International Oncofertility Society and the American Academy of Pediatrics.

What Challenges Arise in Practice?

According to Dr. H. Irene Su and Dr. Mahmoud Salama, there are three main barriers to implementing these guidelines:

1. Time management: Oncologists are often very busy and may lack sufficient time for each patient's fertility assessment.

2. Shortage of specialists: Not every center has experienced reproductive medicine teams or the necessary equipment.

3. Financial difficulties: High out-of-pocket costs prevent some patients from accessing these services.

Looking Ahead

ASCO's 2025 guideline aims to protect patients' present health and their future family plans. Early referral, repeated discussions, and individualized approaches can help every patient make informed decisions about reproductive health.