How I Approach Fertility Discussions in Pediatric, Adolescent, and Young Adult Patients With Cancer Predisposition Syndromes.

Cancer predisposition syndromes (CPS) are identified in up to 20% of pediatric cancers and create dual fertility concerns: gonadotoxicity from therapy and heritable transmission risk. We present a practical framework to embed fertility counseling in pediatric, adolescent, and young adult CPS care for patients with a new cancer diagnosis and for those in surveillance without active malignancy. We recommend initiating proactive discussions surrounding fertility preservation (FP) in mid-to-late adolescence for patients with higher-risk syndromes, and referring interested patients for FP. We also address ethical dimensions, including financial toxicity, patient autonomy, and ethics of pre-implantation genetic testing.