How quickly do I need to refer a cancer patient for fertility preservation?

Urgently — within 1 week of diagnosis. The window between cancer diagnosis and starting gonadotoxic treatment (chemotherapy, radiotherapy, surgery) is typically only 2–4 weeks. Egg freezing requires 10–14 days of hormonal stimulation before egg retrieval. Sperm cryopreservation can be arranged within 24–48 hours. The ASCO 2018 guidelines and RANZCOG position statement both recommend that oncofertility discussion occur within 1–2 weeks of any new reproductive-age cancer diagnosis. GPs who see the patient before the oncologist are placed to make this referral first. Saying 'cancer is the priority now — we can talk about fertility later' closes the window.

What are the fertility preservation options for women?

The main options, in order of evidence: (1) Mature oocyte cryopreservation (egg freezing) — 10–14 days of injectable gonadotropin stimulation, then ultrasound-guided egg retrieval under sedation; gold standard for adults and adolescents who can delay treatment 2–3 weeks; vitrification achieves >99% oocyte survival on thaw. (2) Embryo cryopreservation — same process with IVF fertilisation using partner or donor sperm; higher per-embryo success rate but requires partner or donor commitment. (3) Ovarian tissue cryopreservation (OTC) — laparoscopic ovarian cortex biopsy and freezing; only option for prepubertal girls or emergency situations where stimulation isn't possible; now considered standard care by ASCO 2018, not experimental. (4) GnRH agonist during chemotherapy (goserelin) — partial protection; does not replace cryopreservation. (5) Ovarian transposition before pelvic radiotherapy.

What are the fertility preservation options for men and adolescent boys?

Sperm cryopreservation is first-line for post-pubertal males — rapid, inexpensive (~$300–500/storage/year), and usable even with poor counts. Two samples collected 48 hours apart are preferred. For azoospermia (no sperm in ejaculate), testicular sperm extraction (TESE) by a urologist can retrieve sperm for cryopreservation. For prepubertal boys who cannot yet produce semen, testicular tissue cryopreservation is available at some centres — considered investigational but offered at major paediatric oncology centres. The RANZCOG and Fertility Society of Australia and New Zealand (FSANZ) support routine pre-treatment sperm banking for all post-pubertal male cancer patients. Referral to urology or andrology alongside oncology is the standard pathway.

Is fertility preservation covered by Medicare or PBS in Australia?

Partially, and variably. Medical oncofertility (for cancer treatment) has better access than elective social egg freezing. MBS items exist for the stimulation cycle monitoring consultations (standard specialist items) and for IVF egg retrieval procedures (item 13218 range) — but the specialist consultation and laboratory fees are only partially offset. Some state health systems (Royal Women's Hospital Victoria, Westmead NSW, Women's and Children's Adelaide, Queensland Children's Hospital) have state-funded or subsidised oncofertility programs for cancer patients, often covering one stimulation cycle. Sperm cryopreservation is largely out-of-pocket (~$300–500 for collection and storage per year). Total cost for an oocyte freezing cycle in the private sector is approximately $8,000–12,000 without state-funded support. The referring GP should discuss cost proactively and identify the patient's nearest state-funded oncofertility program.

Do patients on gender-affirming hormones need fertility preservation?

Yes — fertility preservation should ideally be offered and completed before starting gender-affirming hormone therapy or surgery. Oestrogen therapy in trans women causes progressive, and often irreversible, spermatogenesis impairment. Testosterone therapy in trans men suppresses ovulation and may be reversible but the long-term data are uncertain. Trans women: sperm cryopreservation before oestrogen, or after a testosterone washout period if already on hormones. Trans men: oocyte or embryo cryopreservation before testosterone, or after temporary cessation under specialist guidance. The FSANZ position statement and RANZCOG document both support fertility preservation for gender-affirming care as a standard discussion. Many trans and gender-diverse young people do not wish to pursue FP — the obligation is to discuss the option, not to require uptake.

Fertility preservation (oncofertility and pre-gonadotoxic)

Fertility preservation: the AU general practice approach

By Dr HB Lo, FACRRM Reviewed 26 September 2026 8 min read

Fertility preservation banks reproductive cells or tissue before treatments that cause gonadal damage — most commonly cancer treatment requiring chemotherapy, pelvic radiotherapy, or radical surgery.

The GP's critical role: diagnosis to treatment start is often only 2–4 weeks. Every reproductive-age patient facing gonadotoxic treatment must be offered a fertility preservation discussion within 1–2 weeks of diagnosis (ASCO 2018, RANZCOG).

Female options: oocyte cryopreservation, embryo freezing, ovarian tissue cryopreservation. Male options: sperm cryopreservation. Refer urgently — within one week — to an IVF centre with an oncofertility program.

The fertility window that closes

Fertility preservation (FP) is the umbrella term for interventions that bank reproductive cells or tissue before treatments expected to cause gonadal damage — preserving the option of biological parenthood for a future date. This is an act of preparation, not treatment of existing infertility.

The most common context in Australian general practice is oncofertility: a patient — often young — receives a cancer diagnosis and needs to start gonadotoxic chemotherapy, pelvic or cranial radiotherapy, or undergo radical surgery. Between diagnosis and treatment start, there is a narrow window — typically 2–4 weeks — to refer, assess, and bank gametes or tissue.

The GP who sees the patient first can make or close this window. ASCO 2018 guidelines and RANZCOG guidance both mandate FP discussion within 1–2 weeks of any reproductive-age cancer diagnosis. Framing it for the patient: “We need to think about your fertility this week, even though cancer is the priority. There are options that don’t delay your treatment by much.”

Beyond oncofertility, FP applies to: pre-autoimmune therapy (cyclophosphamide for lupus, ANCA vasculitis), pre-bone-marrow transplant, elective oophorectomy for hereditary cancer risk (BRCA1/2), gender-affirming care (before hormones or surgery), and elective social egg freezing (increasingly common, largely out-of-pocket in Australia).

A. Core clinical — the AU general-practice framework

Who needs the conversation

Every reproductive-age patient (roughly 15–45 years) before:

Any cytotoxic chemotherapy — highest risk: alkylating agents (cyclophosphamide, ifosfamide, busulfan, chlorambucil, melphalan); intermediate: taxanes, platinum compounds; lower but not negligible: anthracyclines, fluorouracil
Pelvic radiotherapy (cervical, bowel, bladder, sarcoma, prostate) — ovarian dose >2 Gy causes significant fertility damage; ovarian transposition can reduce scatter dose
Cranial or craniospinal radiotherapy — hypothalamic-pituitary axis damage impairs gonadotropin release
Bilateral oophorectomy / orchiectomy — elective (BRCA, gender-affirming) or therapeutic (ovarian cancer, testicular cancer)
Radical prostatectomy — retrograde ejaculation; sperm cryopreservation offers future ICSI option
BMT conditioning regimens — myeloablative conditioning is highly gonadotoxic
Alkylator-heavy autoimmune therapy — cyclophosphamide for lupus nephritis, ANCA vasculitis; cumulative dose governs risk

Paediatric and adolescent patients — require paediatric oncology + adolescent FP team; consent from parent + age-appropriate assent from the child; prepubertal options include ovarian tissue cryopreservation (girls) and testicular tissue cryopreservation (boys, investigational).

Assessing gonadotoxic risk

The risk to fertility depends on: age at treatment (ovarian reserve declines with age; prepubertal testis more resistant), cumulative chemotherapy dose (cyclophosphamide equivalent dose — CED), radiotherapy field and dose, and surgical extent. eviQ provides AU-specific risk stratification tables by regimen; high-risk regimens include BEACOPP for Hodgkin lymphoma, myeloablative BMT conditioning, and cumulative cyclophosphamide dose >7.5 g/m².

Referral pathway

Refer urgently (within 1 week) to:

Female patients — fertility-specialist gynaecologist at an IVF centre with an oncofertility program; state-funded programs available at major public hospitals (see D below)
Male patients — urology/andrology or directly to sperm bank for cryopreservation; most ART clinics accept urgent referrals for sperm banking within 24–48 hours
Paediatric/adolescent — paediatric oncofertility team at the nearest children’s hospital with a reproductive medicine unit

The Cancer Council Australia fertility page and Sony Foundation You Can service are useful patient-facing resources to hand over at the time of referral.

B. Evidence — female fertility preservation options

Oocyte cryopreservation (egg freezing)

Now considered standard of care per ASCO 2018 and ESHRE 2020:

Process: 10–14 days of subcutaneous gonadotropin (FSH ± LH) stimulation → trigger injection → ultrasound-guided transvaginal oocyte retrieval under sedation
Timing: Can start in any phase of the menstrual cycle using “random-start” protocol developed for oncofertility; reduces the wait by up to 3 weeks compared to waiting for the right menstrual cycle phase
Yield: Approximately 10–15 mature oocytes per cycle (AMH and age-dependent)
Live-birth potential: ~5% per oocyte at age under 35; ~3% at 36–40; ~1–2% at over 40 per Doyle et al (Fertil Steril 2016)
Vitrification: Current standard freezing method; >99% oocyte survival on thaw; superior to slow-freeze
Duration: 2–3 weeks from referral to egg retrieval; does not delay cancer treatment materially in most regimens

Embryo cryopreservation

Same stimulation and retrieval process followed by IVF or ICSI fertilisation with partner or donor sperm. Per-embryo live-birth rates (30–40% per blastocyst transfer) are higher than per-oocyte rates, making it preferable when the patient has a partner and can make the fertilisation decision. Legally, both partners’ consent is required; embryo disposition is legally complex if the relationship ends. Donor sperm is available in Australia through accredited sperm banks.

Ovarian tissue cryopreservation (OTC)

Laparoscopic removal and cryopreservation of ovarian cortical strips. Auto-transplantation is performed years later, restoring natural hormone production and fertility. The only option for prepubertal girls and the preferred approach when treatment is too urgent for stimulation. ASCO 2018 no longer classifies OTC as experimental — over 200 live births worldwide. Available at major oncofertility centres in Australia (FSANZ maintains a registry of accredited centres).

A caution: OTC should not be used if the primary cancer involves ovarian tissue (leukaemia, some lymphomas) — risk of reintroducing malignant cells on auto-transplant.

GnRH agonist co-treatment

The POEMS trial (NEJM 2015) showed goserelin during chemotherapy for hormone-receptor-negative breast cancer reduced premature ovarian insufficiency and improved pregnancy rates. It is not a substitute for cryopreservation but is an additional option when stimulation isn’t possible. Its protective mechanism in other tumour types and regimens is not established.

C. Male fertility preservation

Sperm cryopreservation

First-line and urgent. Most pathology labs and andrology services can process samples within 24–48 hours. Two samples collected 48 hours apart improve the bank. Effective even with low counts; ICSI can achieve fertilisation from a single viable sperm.

Cost: ~$300–500 per year for storage; collection fee varies by centre. Largely out-of-pocket; no Medicare rebate for sperm banking per se, though consultation items apply.

Azoospermia: If the ejaculate contains no sperm (treatment-related or pre-existing), TESE by a urologist can retrieve testicular sperm. Refer urgently if azoospermia is found on semen analysis.

Retrograde ejaculation (post-prostatectomy, post-pelvic surgery, autonomic neuropathy): urine alkalinisation + masturbation recovers sperm; refer to urology/andrology.

D. Australian operations

State-funded oncofertility programs

Major public centres with dedicated oncofertility pathways:

Royal Women’s Hospital, Melbourne (Vic) — Oncofertility Service: subsidised cycles for cancer patients
Westmead Hospital Reproductive Medicine Unit (NSW) — public funding for eligible patients
Women’s and Children’s Hospital, Adelaide (SA) — paediatric + adult oncofertility
Queensland Children’s Hospital + Mater Mothers’ (QLD) — paediatric + young adult
King Edward Memorial Hospital (WA) — reproductive endocrinology referral for FP

Equity gap: rural and remote patients, Aboriginal and Torres Strait Islander patients, and low-SES patients have lower access and lower FP uptake. Telehealth consultations with metropolitan IVF centres have partially addressed the rural gap.

Cost and MBS

Stimulated cycle monitoring (specialist consultations) uses standard MBS items. The IVF-related items (MBS 13218 range — follicle aspiration) may have partial rebate. State health subsidies vary: some programs cover one cycle plus storage for a fixed period (typically 10 years, extendable by application). Private out-of-pocket cost: $8,000–12,000 per stimulated cycle including monitoring, retrieval, vitrification, and one year of storage. Sperm banking: $300–500/year, no meaningful rebate.

eviQ has oncofertility referral pathways searchable by state and cancer type — a GP can use this directly.

Storage duration and future use

All Australian states permit storage for up to 10 years (standard) with application for extension. The decision to use, donate, or discard stored gametes/embryos is the patient’s. GPs caring for cancer survivors should periodically revisit the patient’s reproductive plans — many patients who banked material never receive a question about it from their GP or oncologist.

E. Special populations

Transgender and gender-diverse patients. Fertility preservation is a standard pre-hormone discussion. Trans women: sperm cryopreservation before oestrogen commences (or after testosterone washout). Trans men: oocyte cryopreservation before testosterone; temporary cessation of testosterone under specialist guidance allows stimulation. Many young trans patients decline FP — the obligation is to offer and document; not to insist. The FSANZ position supports these discussions as standard care.

BRCA1/2 and hereditary cancer syndromes. BRCA1/2 carriers facing risk-reducing salpingo-oophorectomy at 35–40 years should discuss FP before the procedure if they haven’t completed childbearing. Pre-implantation genetic testing (PGT-M) for BRCA and other hereditary syndromes is available in Australia through accredited IVF centres, allowing embryo selection before transfer.

Premature ovarian insufficiency (POI). Young women with known or evolving POI (Turner syndrome, fragile-X carriers, autoimmune POI) can be offered OTC or oocyte cryopreservation before follicular reserve is exhausted. Timing is important — refer early. RANZCOG has guidance on this subset.

Adolescents. The ethical framework: parental consent plus age-appropriate assent from the adolescent. Psychological support is essential. Sydney Children’s Network and RCH Melbourne have adolescent oncofertility protocols.

When to escalate

Urgent (within 1 week):

Any reproductive-age patient with a new cancer diagnosis facing chemo, radiotherapy, or radical surgery
Pre-BMT conditioning in any reproductive-age patient
Pre-bilateral oophorectomy for BRCA in a woman who has not completed childbearing
Adolescent with a new cancer diagnosis — paediatric oncofertility team

Non-urgent referral:

Pre-autoimmune cyclophosphamide therapy in reproductive-age patients
Pre-gender-affirming hormones or surgery — fertility discussion before initiation
Elective social egg freezing — refer to any FSANZ-accredited IVF centre
Survivors returning to discuss use of banked material — reproductive endocrinology

What this article is and is not

This is general health information drawn from current Australian guidelines — RANZCOG, FSANZ, eviQ, eTG, AMH, RACGP, Cancer Council Australia — and major fertility preservation literature (ASCO 2018, ESHRE 2020). It is not personal medical advice and does not create a doctor–patient relationship. Decisions about fertility preservation options, timing, and access are made with the patient and their oncofertility specialist.

For Australian patient resources: Cancer Council Australia — fertility and cancer, Sony Foundation You Can, HealthDirect — Fertility preservation.

Sources cited

Frequently asked questions

How quickly do I need to refer a cancer patient for fertility preservation?

Urgently — within 1 week of diagnosis. The window between cancer diagnosis and starting gonadotoxic treatment (chemotherapy, radiotherapy, surgery) is typically only 2–4 weeks. Egg freezing requires 10–14 days of hormonal stimulation before egg retrieval. Sperm cryopreservation can be arranged within 24–48 hours. The ASCO 2018 guidelines and RANZCOG position statement both recommend that oncofertility discussion occur within 1–2 weeks of any new reproductive-age cancer diagnosis. GPs who see the patient before the oncologist are placed to make this referral first. Saying 'cancer is the priority now — we can talk about fertility later' closes the window.
What are the fertility preservation options for women?

The main options, in order of evidence: (1) Mature oocyte cryopreservation (egg freezing) — 10–14 days of injectable gonadotropin stimulation, then ultrasound-guided egg retrieval under sedation; gold standard for adults and adolescents who can delay treatment 2–3 weeks; vitrification achieves >99% oocyte survival on thaw. (2) Embryo cryopreservation — same process with IVF fertilisation using partner or donor sperm; higher per-embryo success rate but requires partner or donor commitment. (3) Ovarian tissue cryopreservation (OTC) — laparoscopic ovarian cortex biopsy and freezing; only option for prepubertal girls or emergency situations where stimulation isn't possible; now considered standard care by ASCO 2018, not experimental. (4) GnRH agonist during chemotherapy (goserelin) — partial protection; does not replace cryopreservation. (5) Ovarian transposition before pelvic radiotherapy.
What are the fertility preservation options for men and adolescent boys?

Sperm cryopreservation is first-line for post-pubertal males — rapid, inexpensive (~$300–500/storage/year), and usable even with poor counts. Two samples collected 48 hours apart are preferred. For azoospermia (no sperm in ejaculate), testicular sperm extraction (TESE) by a urologist can retrieve sperm for cryopreservation. For prepubertal boys who cannot yet produce semen, testicular tissue cryopreservation is available at some centres — considered investigational but offered at major paediatric oncology centres. The RANZCOG and Fertility Society of Australia and New Zealand (FSANZ) support routine pre-treatment sperm banking for all post-pubertal male cancer patients. Referral to urology or andrology alongside oncology is the standard pathway.
Is fertility preservation covered by Medicare or PBS in Australia?

Partially, and variably. Medical oncofertility (for cancer treatment) has better access than elective social egg freezing. MBS items exist for the stimulation cycle monitoring consultations (standard specialist items) and for IVF egg retrieval procedures (item 13218 range) — but the specialist consultation and laboratory fees are only partially offset. Some state health systems (Royal Women's Hospital Victoria, Westmead NSW, Women's and Children's Adelaide, Queensland Children's Hospital) have state-funded or subsidised oncofertility programs for cancer patients, often covering one stimulation cycle. Sperm cryopreservation is largely out-of-pocket (~$300–500 for collection and storage per year). Total cost for an oocyte freezing cycle in the private sector is approximately $8,000–12,000 without state-funded support. The referring GP should discuss cost proactively and identify the patient's nearest state-funded oncofertility program.
Do patients on gender-affirming hormones need fertility preservation?

Yes — fertility preservation should ideally be offered and completed before starting gender-affirming hormone therapy or surgery. Oestrogen therapy in trans women causes progressive, and often irreversible, spermatogenesis impairment. Testosterone therapy in trans men suppresses ovulation and may be reversible but the long-term data are uncertain. Trans women: sperm cryopreservation before oestrogen, or after a testosterone washout period if already on hormones. Trans men: oocyte or embryo cryopreservation before testosterone, or after temporary cessation under specialist guidance. The FSANZ position statement and RANZCOG document both support fertility preservation for gender-affirming care as a standard discussion. Many trans and gender-diverse young people do not wish to pursue FP — the obligation is to discuss the option, not to require uptake.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.