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Some cancer treatments can stop a child having children of their own later. Before treatment, the team should talk with the family about this risk and refer them to a fertility specialist if they want, or are unsure. Teenagers who have started puberty can bank sperm or eggs; for younger girls ovarian tissue can be frozen, and for younger boys testicular tissue freezing is still experimental.
Children's Oncology Group endorses the ASCO 2025 guideline update (166 studies, GRADE) for children. Discuss the possibility of infertility as early as possible before treatment (strong, moderate), offer an evaluation of reproductive risk that accounts for the gonadotoxicity of planned and possible future treatment (strong, moderate), and refer anyone interested or uncertain to reproductive specialists as soon as possible (strong, very low), with prompt access to a multidisciplinary fertility preservation team (good practice). Children and adolescents who have started puberty should be offered established methods with their assent and parental consent (strong, moderate): sperm banking for all pubertal and postpubertal males before treatment (strong, high), with testicular sperm extraction if no sample can be produced (strong, high), and embryo or oocyte cryopreservation in females (strong, high). For prepubertal patients the only options are ovarian tissue cryopreservation, an established method that needs no ovarian stimulation or delay (strong, moderate), and testicular tissue cryopreservation, which is experimental and for trials only (strong, very low). Hormonal suppression does not protect male fertility (strong, high); GnRH agonists must not replace established methods (conditional, moderate). Ovarian transposition may be offered before pelvic radiotherapy (strong, moderate). Revisit fertility at follow-up and when plans change (strong, low).
Why: Many options must be done before the first dose of treatment, so a late conversation can close them off.
“FP approaches should be discussed before cancer-directed therapy.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Moderate quality evidence
Why: Risk differs between treatments, and for many newer treatments it is not yet known, so the family needs to hear what applies to their child.
“People with cancer should be evaluated for and counseled about reproductive risks at diagnosis and during survivorship.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Moderate quality evidence
Why: Uncertain families benefit from expert advice too, and delay can rule options out.
“Patients interested in or uncertain about FP should be referred to reproductive specialists.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Very low quality evidence
Why: Fertility specialists, psychological support, social work, financial counselling and genetic counselling may all be needed within days.
“Oncology teams should ensure prompt access to a multidisciplinary FP team.”
ASCO, Journal of Clinical Oncology 2025 · Good practice statement
Why: A young person who has begun puberty can usually store sperm or eggs, and their own agreement matters alongside the parents'.
“Established FP methods in children who have begun puberty should be offered with patient assent and parent/guardian consent.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Moderate quality evidence
Why: Frozen sperm is the most reliable way for a boy to keep the chance of biological children; even a small sample can be used later.
“Sperm cryopreservation should be offered to males before cancer-directed treatment, with testicular sperm extraction if unable to provide semen samples.”
ASCO, Journal of Clinical Oncology 2025 · Strong, High quality evidence
Why: Sperm collected soon after starting treatment may carry more genetic damage; modern IVF can use very few sperm.
“Males should be advised of potentially higher genetic damage risks in sperm collected soon after cancer-directed therapy initiation and completion.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Low quality evidence
Why: Both are established methods; stimulation no longer has to wait for a particular day of the cycle.
Children's Oncology Group 2025 · Strong, High quality evidence
Why: It needs no hormone stimulation or delay and is the only established option before puberty.
“The only established method for prepubertal females is OTC.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Moderate quality evidence
Why: The method is still investigational, so it is offered as research rather than as routine care.
“Testicular tissue cryopreservation in prepubertal males is experimental and should be offered only in a clinical trial.”
ASCO, Journal of Clinical Oncology 2025 · Strong, Very low quality evidence
Why: Hormone suppression is not effective for boys; in girls, ASCO allows GnRH agonists only as an addition, in breast cancer, and asks for trials elsewhere.
“Gonadotropin-releasing hormone agonist (GnRHa) should not be used in place of established FP methods but may be offered as an adjunct to females with breast cancer.”
ASCO, Journal of Clinical Oncology 2025 · Strong, High quality evidence (males); Conditional, Moderate quality evidence (GnRHa)
Why: Moving the ovaries can shield them from radiation, though scatter means it does not always work.
Children's Oncology Group 2025 · Strong, Moderate quality evidence
Why: A child's wishes change as they grow up, and options such as egg or embryo freezing remain possible after treatment for some.
Children's Oncology Group 2025 · Strong, Low quality evidence
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ASCO 2025 guideline update, endorsed by the Children's Oncology Group in June 2025, is the current standard and replaces the 2018 version: early discussion and risk assessment before treatment, immediate referral for anyone interested or uncertain, established methods for pubertal children with their assent and parental consent, ovarian tissue cryopreservation as an established method for prepubertal girls, and testicular tissue cryopreservation for prepubertal boys only in trials. The PanCareLIFE and IGHG recommendations (2021) cover the same ground for patients diagnosed at 25 or younger with GRADE; they were read only as abstracts here, so where they differ from ASCO is not stated.
Children's Oncology Group 2025 · ASCO, Journal of Clinical Oncology 2025 · PanCareLIFE and IGHG, The Lancet Oncology 2021 · PanCareLIFE and IGHG, The Lancet Oncology 2021
Where it differs: Gives a GnRH agonist when chemotherapy must start urgently, for its benefits such as suppressing periods, rather than as a fertility method.
Evidence: ASCO 2025, conditional recommendation, low quality evidence.
Children's Oncology Group 2025 · ASCO, Journal of Clinical Oncology 2025
Fewer than half of patients starting treatment that can damage fertility have a documented fertility discussion or referral, with worse rates for women, minorities and patients outside academic centres. An order-set trigger that refers every patient under 40 to reproductive medicine unless they actively decline would make the conversation routine and timely.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Discuss infertility as early as possible before treatment | Strong, Moderate quality evidence | Children's Oncology Group 2025 |
| Refer interested or uncertain patients to reproductive specialists | Strong, Very low quality evidence | Children's Oncology Group 2025 |
| Established methods for children who have begun puberty, with assent and consent | Strong, Moderate quality evidence | Children's Oncology Group 2025 |
| Sperm cryopreservation before treatment | Strong, High quality evidence | Children's Oncology Group 2025 |
| No hormonal suppression to preserve male fertility | Strong, High quality evidence | Children's Oncology Group 2025 |
| Testicular tissue cryopreservation in prepubertal males only in trials | Strong, Very low quality evidence | Children's Oncology Group 2025 |
| Ovarian tissue cryopreservation as an established method | Strong, Moderate quality evidence | Children's Oncology Group 2025 |
| GnRH agonists not in place of established methods | Conditional, Moderate quality evidence | Children's Oncology Group 2025 |
| Ovarian transposition before pelvic radiotherapy | Strong, Moderate quality evidence | Children's Oncology Group 2025 |
Shares Default fertility preservation referral for every patient under 40 before treatment, Fertility in boys and young men treated for cancer, including testicular tissue banking, Fertility in girls and young women treated for cancer, including ovarian tissue freezing, Goserelin / leuprolide (ovarian function suppression) and the tags protocol, fertility.
Shares American Society of Clinical Oncology (ASCO), Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares American Society of Clinical Oncology (ASCO), Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types), Late effects and survivorship toxicity and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.
Shares Children's Oncology Group (COG), Childhood cancers (all types) and the tags protocol, paediatric.