As an integrated oncology and FP approach, oncofertility provides comprehensive care that considers cancer survivors’ long-term reproductive goals and quality of life in the aftermath of the cancer. Incorporating oncofertility into routine clinical practice requires adequate awareness and positive attitudes among HCPs [7]. The topic of oncofertility warrants evaluation in low- and middle-income countries (LMICs) due to several factors, including the rising incidence of cancer, sociocultural considerations, and limited resources [16,17,18]. To achieve this goal, we conducted a survey-based assessment of oncofertility awareness and attitudes among HCPs in Iran.

According to the survey, Iranian HCPs have varying levels of awareness regarding oncofertility. Although oncology field healthcare participants thoroughly understood oncofertility practices and principles, others have demonstrated limited knowledge. Discrepancies in knowledge levels highlight the need for targeted education and intervention programs. Several factors may contribute to the observed variance in oncofertility awareness. Lack of awareness among HCPs may be due to the lack of formal training and educational opportunities specific to oncofertility in medical curricula and residency programs, which can result in suboptimal care for cancer patients [15, 19]. According to different studies, oncofertility education should be included in medical training to ensure comprehensive care for cancer patients [20]. The development and implementation of oncofertility education programs for HCPs in Iran are therefore necessary.

Moreover, attitudes toward oncofertility play an essential role in integrating FP services into cancer treatment. While some participants expressed positive attitudes toward oncofertility and recognized its importance, others were skeptical. There may be misconceptions associated with negative attitudes, such as concerns regarding treatment delays or a lack of awareness of available FP techniques. This negative attitude impedes patients from taking necessary FP strategies, ruins their possible opportunity for childbearing, and can hamper referrals [15, 21, 22].

Many barriers hinder the implementation of oncofertility practices in different settings, especially in developing countries. These barriers include delays in the management of cancer due to time-consuming fertility procedures, limited awareness among HCPs and patients about the fertility risks of specific treatments, and lack of knowledge about available FP methods [18]. Several studies have investigated educational programs targeting HCPs regarding FPs for cancer patients. These studies consistently indicate that such programs can improve healthcare personnel’s knowledge and attitudes toward oncofertility [23]. For example, Zhang et al. [24] systematically reviewed five educational programs for HCPs. Four significantly increased medical staff’s understanding of FP, but only one improved their clinical practice.

Additionally, Tholeti et al. [22] reported that 60% of primary care physicians in India had inadequate knowledge of FP options, and only 26–32% were aware of international guidelines recommending FP for cancer patients. According to the article, increasing awareness of FP in India may facilitate successful referrals to oncofertility clinics. This is supported by the findings of our study, where a significant number of cases described delays in cancer treatment precisely due to referrals to clinics or fertility counseling services. More than 88% of oncology and OB/GYN participants reported such delays. In addition to a lack of knowledge, poor inter-institutional communication may contribute to this prolonged referral process. In combination, these factors may prevent timely transitions of patients from primary care settings to specialized oncofertility clinics [22].

Moreover, a study by Zhao et al. assessed oncofertility awareness and attitudes among oncologists in China and found that 84.8-88.7% of oncologists reported positive attitudes about oncofertility and discussing fertility-sparing options. In comparison, only 11.8% of oncologists reported frequently referring their patients to fertility preservation facilities [23]. Our study also showed that this discrepancy emphasizes the difficulty of translating knowledge and positive attitudes into routine clinical practice.

Multiple studies have shown that knowledge and attitudes toward oncofertility vary across different regions of the world, with some regions facing major barriers to oncofertility practice, such as cultural or religious restrictions. The lack of insurance coverage and funding for oncofertility services may also contribute to high patient costs. Another barrier to the successful implementation of fertility preservation techniques is the availability of specialized laboratories, equipment, and personnel in LMICs, as observed in a similar study [18].

Aside from healthcare-related barriers, there are also critical patient-specific factors to consider. Many patients, especially adolescents, may lack the cognitive maturity and awareness to entirely understand the implications of infertility and the available fertility preservation opportunities. This can impede informed decision-making and even delay referrals. Additionally, some patients may feel unpleasant discussing fertility issues, particularly when facing a cancer diagnosis. Furthermore, fertility considerations often compete with the urgent concerns related to cancer treatment itself, further complicating the decision-making process [25].

Despite these challenges, there are many opportunities to improve oncofertility practices and patients’ outcomes in different contexts, for instance, increasing education and training for HCPs and patients on oncofertility issues using various modalities such as online courses, workshops, and seminars. Moreover, adding oncofertility subjects to the medical school curriculum might be beneficial. In addition, multidisciplinary teams and networks can also be established to collaborate and coordinate oncofertility care across different specialties and institutions [18]. Furthermore, implementing system-based solutions facilitates the identification and referral of patients who may benefit from oncofertility services [20, 26, 27]. Therefore, advocating for policy changes and funding support would help patients in developing countries such as Iran.

Other studies have assessed knowledge and attitudes among healthcare providers in Iran [28, 29]. However, these studies have focused primarily on specialties such as oncology, gynecology, obstetrics, and embryology, which naturally possess more information about FP. Incorporating perspectives from diverse healthcare specialties is necessary because effective FP care requires a multidisciplinary approach. Different healthcare providers have unique perspectives and expertise and provide holistic care to patients.

Another essential aspect that deserves attention is the limited prevalence of well-established official national oncofertility registries worldwide. The findings from a pilot study revealed a remarkably limited number of countries that have successfully established national oncofertility registries. Specifically, the study identified Australia, Germany, and Japan as the exclusive countries with such registries in place, underscoring this achievement’s rarity [30].

Education enhancement: Targeted educational programs and resources could be developed to ensure that HCPs are well-informed about oncofertility options and can effectively communicate these options to their patients.

Policy making and insurance: Efforts should be made to include oncofertility in government and insurance policies. This approach would help secure the necessary funding and infrastructure for fertility preservation programs.

Patient counseling: It is crucial to address well-known negative attitudes toward FP methods among both HCPs and patients and implement comprehensive counseling services to support patients in informed decision-making about fertility preservation options.

Monitoring: Establishing a framework for longitudinal and long-term monitoring, including the development of national registries or collaborative studies to assess the impact of interventions aimed at improving oncofertility awareness and attitudes.

By addressing these fundamental areas, it is possible to make substantial strides in improving the landscape of oncofertility in Iran. This approach will ultimately enhance the available support for cancer patients.

There are several limitations to consider in our study. Due to the self-reported nature of the survey, it may not fully reflect actual FP practices among HCPs, and such surveys are an acceptable compromise due to the lack of objective measures. The study also did not examine the reasons behind the low attitudes of HCPs. Furthermore, participants may have provided responses influenced by their social desires or other circumstances, and data reliability and accuracy could be affected. A more comprehensive understanding of this topic requires further research to address these limitations.