Poor health literacy may complicate education regarding FP [4]. Not only do clinicians have to relay the information so the patient can understand, but educational materials also need to be on the literacy level of each patient. Schover et al. found that men who banked sperm were younger, more likely to have been childless, and more highly educated [11]. Patients presenting with late-stage disease with a poor prognosis can make communication of FP more challenging [4]. Goals of therapy with advanced disease are often palliative and focused on symptom management rather than future childbearing potential. Patients may also be too physically ill to bank sperm or explore FP options [17]. Select patients are interested in posthumous parenting where a patient stores sperm or embryos and then uses the stored material for assisted reproduction with a partner after the patient’s death; however this remains controversial [4]. Some patients require more urgent treatment at the time of diagnosis and clinicians are hesitant for them to have a treatment delay to pursue FP [5]. Peddie et al. identified in a survey of both patients and health-care providers that one of the primary barriers to pursuing FP was the “urgent need for treatment” conveyed by staff [20].

Pediatric and adolescent providers face different challenges compared to adult oncology providers. First, communication of FP may be difficult based on the patient’s age and understanding of reproduction. While providers are looking to follow the patient’s wishes, they ultimately have to obtain legal approval from the guardians [4]. Second, providers and/or families may be uncomfortable with the discussion of sexuality, reproduction, and techniques of FP (specifically ejaculation) in this population. Vadaparampil et al. collected data from 24 pediatric oncologists in Florida at 13 children’s cancer centers and found that half of physicians believed that parents wanted information about FP while the other half thought that parents were either uncomfortable with the discussion or solely focused on their children’s treatment plan [18]. Some of the physicians looked for cues from parent’s body language to gauge their comfort with the discussion and others pushed through trying to educate on the importance of FP [18]. In this study, 5 of the 24 physicians described clinical scenarios where the parents wanted the patient to sperm bank; however the patient refused. No one reported the opposite scenario where the patient desired sperm banking and the parents refused consent. Achille et al. interviewed 20 adolescent cancer survivors of either Hodgkin’s lymphoma or testicular cancer and 18 health-care professionals and found that patients did not typically view sperm banking as a difficult procedure and that having a supportive parent was an enabling factor to bank sperm [4, 21].

Pediatric and adult providers also face similar challenges discussing fertility preservation. One provider barrier previously discussed in detail is lack of knowledge and availability of patient education material . Second, providers have time constraints with each patient due to high patient caseloads. A majority of the initial visits are focused on discussing the cancer diagnosis and treatment plan and this leaves little time to discuss future considerations of cancer survivorship, including FP. Caprice Knapp points out in the chapter, “Healthcare Provider Perspectives on Fertility Preservation for Cancer Patients,” that current guidelines do not address that discussions about FP may not be completed in one session and need to be ongoing. The discussions should not be viewed as a “one-time task to be checked off on a care plan, but as an evolution of health information exchanges [4].”

Barriers exist at a socioeconomic level that prevent effective FP. Patients undergoing cancer treatment are subject to high costs of therapy even with adequate insurance coverage due to large co-pays. For males, sperm cryopreservation is rarely covered by insurance [22, 23]. ASCO guidelines on FP estimate the cost of sperm banking at approximately $1500 for three samples stored for 3 years with a storage fee for additional years [6, 22]. Some studies suggest that potential cost is a barrier for providers to enthusiastically support FP [4, 24, 25]. Organizations, such as Fertile Hope , offer programs that include discounted nationwide sperm banking and fertility preservation services [22]. Cultural and geographic barriers also exist where certain patient populations may not endorse and even discourage artificial assistance with reproduction. This may also then prevent providers from initiating a discussion on the topic. In other cultures and religions where family and children are of high priority and adoption is prohibited, FP may be essential [8].