​Why It Matters

Fertility is an important survivorship issue for many adolescents, young adults, and individuals of reproductive age diagnosed with cancer. Cancer treatments—including chemotherapy, radiotherapy, surgery, endocrine therapy, and some targeted therapies—can impair reproductive function by damaging the ovaries, testes, uterus, or hypothalamic-pituitary axis. The impact varies depending on treatment type, cumulative dose, age at treatment, and baseline fertility.

Discussions about fertility are often overlooked despite their significant impact on quality of life and future family planning. Studies have shown that many patients do not receive adequate counselling regarding infertility risk before treatment, with reported counselling rates ranging from 34–70%, and only 44% of reproductive-aged patients in one large study recalled discussing chemotherapy-related infertility risks.

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Healthcare professionals play a key role in ensuring that fertility is addressed proactively. Fertility discussions should occur before treatment whenever possible, continue throughout survivorship, and be revisited if treatment plans change or reproductive goals evolve.

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Practical Clinical Approach

Many patients wait for clinicians to raise the topic of fertility, while clinicians may assume it is not a priority. Fertility should therefore be discussed routinely with all patients of reproductive age, regardless of diagnosis, relationship status, sexual orientation, gender identity, or whether they currently express a desire for children.

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A simple introduction may include:

"Some cancer treatments can affect fertility or future family planning. I discuss this with all patients of reproductive age because there are options that may help preserve fertility before treatment begins."

or

"Have you thought about whether having biological children in the future is important to you?"

These conversations should be survivor-centred, non-judgemental, and documented in the medical record.

 

 

Practical Screening Questions

Fertility goals

• Do you hope to have biological children in the future?

• Has your cancer diagnosis changed your thoughts about having children?

• Is preserving fertility important to you?

Treatment understanding

• Has anyone discussed how your cancer treatment may affect fertility?

• Do you have concerns about infertility after treatment?

Current reproductive health

For patients assigned female at birth:

• Have your menstrual periods changed since treatment?

• Have you noticed symptoms of early menopause?

For patients assigned male at birth:

• Have you noticed changes in sexual function, ejaculation, or concerns about fertility?

Family planning

• Are you currently trying to conceive?

• Are you using contraception?

• Would you like a referral to discuss fertility preservation or fertility assessment?

 

 

How Cancer Treatment Can Affect Fertility

Cancer treatments can impair fertility through several mechanisms.

Chemotherapy and pelvic radiotherapy may damage ovarian follicles or spermatogenesis, resulting in temporary or permanent infertility. Surgery involving reproductive organs may directly affect reproductive capacity, while endocrine therapies may delay pregnancy because of prolonged treatment duration. Radiation can also affect fertility by exposing reproductive organs to gonadotoxic doses, although modern radiation planning techniques can reduce this risk through organ shielding and dose minimization.

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The degree of fertility impairment depends on several factors, including:

• Age at treatment

• Type and dose of chemotherapy

• Radiation field and cumulative dose

• Surgical procedures

• Baseline reproductive function

• Individual susceptibility

 

 

Fertility Preservation

Whenever possible, fertility preservation should be discussed before cancer treatment begins, as pretreatment preservation offers the highest likelihood of future biological parenthood. Early referral to fertility specialists should not unnecessarily delay cancer treatment but should occur promptly after diagnosis.

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Available fertility preservation options include:

Female patients

• Oocyte cryopreservation

• Embryo cryopreservation

• Ovarian tissue cryopreservation

• Ovarian transposition before pelvic radiotherapy (selected patients)

Current evidence suggests that ovarian tissue cryopreservation can result in viable tissue and successful live births following transplantation, although success rates remain lower than conventional IVF-based approaches.

 

Male patients

• Sperm cryopreservation (preferred)

• Testicular sperm extraction (TESE)

• Intracytoplasmic sperm injection (ICSI) for post-treatment azoospermia or very low sperm counts

These techniques may allow successful conception even after gonadotoxic treatment.

For selected premenopausal patients receiving chemotherapy, gonadotropin-releasing hormone (GnRH) agonists may help preserve ovarian function, particularly in breast cancer, although they should not replace established fertility preservation techniques.

 

 

Assessment After Cancer Treatment

Cancer survivors frequently ask whether they remain fertile after treatment. Importantly, clinicians should not assume infertility based on treatment history alone.

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In women, chemotherapy-induced amenorrhoea does not necessarily indicate permanent infertility, as ovarian function and menstruation may recover months or years after treatment. Similarly, irregular menstrual cycles do not reliably predict fertility.

Male survivors may experience reduced sperm count, impaired sperm quality, azoospermia, or difficulties with erection and ejaculation. Fertility may recover over time depending on treatment exposure and individual factors.

Patients wishing to conceive following treatment should be referred for fertility assessment rather than relying solely on clinical history.

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Contraception and Pregnancy

Although fertility may be reduced after treatment, pregnancy can still occur unexpectedly.

Patients should therefore receive counselling regarding contraception if pregnancy is not desired. Cancer survivors have been reported to experience unintended pregnancies at rates approximately three times higher than the general population, highlighting the importance of ongoing contraceptive discussions during survivorship.

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For many cancer survivors, pregnancy after treatment is safe. For example, current evidence indicates that pregnancy after breast cancer does not increase recurrence risk, and previous breast cancer treatment does not increase the risk of congenital abnormalities in future offspring. Traditionally, clinicians have advised waiting approximately 2 years after becoming disease-free before attempting conception because recurrence risk is highest during this period, although recommendations should always be individualized according to tumour type, treatment, and oncology advice.

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Multidisciplinary Care

Fertility counselling should involve a multidisciplinary team whenever possible.

This may include:

• Medical oncologists

• Radiation oncologists

• Reproductive endocrinologists

• Fertility specialists

• Urologists

• Reproductive surgeons

• Oncology nurses

• Genetic counsellors

• Mental health professionals

• Social workers

• Financial counsellors

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Patients often experience emotional distress related to fertility decisions, treatment delays, financial costs, and concerns about hereditary cancer risk. Multidisciplinary support can improve informed decision-making and reduce decisional regret.

 

 

Special Considerations

 

Adolescents and Young Adults (AYA)

Fertility preservation should be considered an integral component of cancer care for adolescents and young adults. Discussions should occur as early as possible after diagnosis, with involvement of parents or caregivers when appropriate while respecting the young person's autonomy and preferences.

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Survivors with Treatment Changes

If a patient's treatment plan changes, fertility risks should be reviewed again. Additional therapies may increase gonadotoxicity, requiring updated counselling and referral.

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Long-Term Survivorship

Fertility discussions should continue beyond treatment completion. Survivors' reproductive goals may change over time, and referrals for fertility assessment should remain available throughout survivorship care.

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Practical Recommendations for HCPs

Healthcare professionals should routinely discuss fertility with all reproductive-aged patients before cancer treatment begins and revisit the conversation throughout survivorship. Discussions should include infertility risk, fertility preservation options, contraception, pregnancy planning, and available specialist services.

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Patients who express interest in future biological children should be referred promptly to fertility specialists before treatment whenever feasible. Following treatment, clinicians should avoid assuming infertility based on amenorrhoea, treatment history, or sexual dysfunction alone. Instead, survivors interested in pregnancy should undergo formal fertility assessment and receive individualized counselling regarding conception timing and reproductive option.