Global disparities in fertility preservation among young breast cancer patients: a systematic review and meta-analysis of utilization rates and associated factors

Abstract

Background Women who develop breast cancer at the age of 40 years or younger often face considerable barriers to fertility preservation services. This systematic review and meta-analysis examined global fertility preservation utilization rates and the factors associated with uptake. Objectives To synthesize the evidence on (1) global fertility preservation utilization rates and (2) factors associated with fertility preservation uptake among young breast cancer patients. Methods We systematically searched five databases (PubMed, EMBASE, Cochrane Library, CINAHL, PsycINFO) and trial registries for studies published from January 2010 to August 2026 involving women aged 40 years or younger with breast cancer. Proportions and odds ratios (ORs) were pooled using random-effects meta-analysis, and heterogeneity was assessed with the I2 statistic. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Eighteen studies (n = 13,394) were included. The pooled fertility preservation utilization rate was 26.8% (95% CI: 20.0–34.1%; I2 = 98.8%). Regional estimates differed widely (Europe 47.8%; Asia 19.8%; North America 14.0%), but the North American estimate was highly imprecise (95% CI: 5.0–26.6%; I2 = 99.3%), so regional comparisons should be interpreted with caution. Older age within the young-patient range (OR 0.71), higher educational attainment (OR 1.58), being partnered (OR 1.74), nulliparity (OR 2.12), and insurance coverage (OR 2.85) were associated with uptake, with specialist referral the strongest enabling factor (OR 4.26). The certainty of evidence was rated low to very low across outcomes. Conclusions Access to fertility preservation appears inequitable worldwide, although substantial heterogeneity and imprecision in some regional estimates preclude definitive cross-regional rankings. Younger age, higher education, partnership status, and insurance coverage were associated with fertility preservation uptake. Because the evidence is observational and heterogeneous, causal inferences should be drawn with caution. Policy reforms supporting insurance coverage and standardized training may improve access to fertility preservation, but further high-quality research is needed.