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Purpose: Fertility preservation is an important issue for premenopausal cancer patients; however, not all patients receive counseling about chemotherapy-induced infertility and potential mitigation strategies. We aimed to identify characteristics of premenopausal breast cancer patients less likely to receive fertility counseling. We also investigated patient recall of chart-documented fertility discussions and patient attitudes toward fertility preservation.Methods: The study was approved by our institution's Institutional Review Board. All female patients with invasive primary breast cancer of any type, aged 40 or younger at the time of diagnosis, who were diagnosed during or up to 5 years prior to the study period were eligible. The study was conducted between February 2012 and October 2013. Enrolled patients completed an anonymous survey, and their medical charts were subsequently reviewed to identify provider documentation of fertility discussions, referral to fertility specialists, or implementation of fertility preservation. Patient comments regarding their fertility were solicited and examined thematically.Results: Forty-nine patients consented to participate. Fertility discussions were documented by providers in 55% of patients. Patients aged over 35 and multiparous patients were significantly less likely than their counterparts (p < 0.01 in both cases) to have had chart-documented fertility discussions. Only 52% of patients with chart-documented discussions recalled having had such a conversation. Patient comments highlighted the difficulty of considering fertility at the time of diagnosis and also the risks and obstacles facing fertility preservation.Conclusions: Despite increasing awareness, fertility is not universally discussed with premenopausal breast cancer patients at the time of diagnosis; older and multiparous patients are at particular risk of not receiving fertility counseling. Even when such discussions are documented, only about half of patients recall the conversation. Patient-reported barriers to fertility preservation include lack of education combined with the stress of diagnosis, financial costs, and perceived treatment toxicities. [ABSTRACT FROM AUTHOR]