How should oncofertility counselling be performed?

[Verified against AUA/ASRM Male Infertility Guideline 2021 — male component] For men, the guideline gives an unusually concrete set of statements: Discuss the effects of gonadotoxic therapies and other cancer treatments on sperm production with patients prior to commencing therapy (Moderate Recommendation, Grade C). Encourage men to bank sperm, preferably multiple specimens where possible, before gonadotoxic therapy (Expert Opinion). Inform patients to avoid pregnancy for at least 12 months after completing treatment (Expert Opinion), based on the known mutagenic effects on developing germ cells. Semen analysis after gonadotoxic therapy should be done at least 12 months and preferably 24 months after completion (Conditional Recommendation, Grade C) — azoospermia rates are highest in the first 12 months and most men recovering sperm do so 2–3 years post-treatment, so earlier testing misleads. Inform men seeking paternity who remain persistently azoospermic after gonadotoxic therapy that TESE is a treatment option (STRONG Recommendation, Grade B). Retrieval is typically deferred until at least two years after chemotherapy; meta-analysis reports a retrieval rate of 42%. Inform patients undergoing retroperitoneal lymph node dissection of the risk of aspermia (Clinical Principle), and obtain post-orgasmic urinalysis for those with aspermia after RPLND who want fertility (Clinical Principle). A systems point the guideline makes directly: only 20–50% of men bank sperm before chemotherapy, and low banking rates have been attributed to inadequate fertility counselling before gonadotoxic therapy. That is a failure of process rather than of patient choice, and it is addressable. For azoospermic men with an intratesticular lesion, cryopreservation of testicular tissue should be considered at orchiectomy or excisional biopsy — the onco-TESE approach. Reviewer: female oncofertility should be added from the ASRM 2026 fertility preservation opinion, which is not covered here.