The opportunity to discuss fertility preservation is essential for patients of reproductive age with newly diagnosed cancer before the initiation of treatment. To identify factors associated with fertility preservation counseling among patients of reproductive age before initiating chemotherapy. This cross-sectional study used data obtained from the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative, an oncologist-led quality assessment program that surveys approximately 400 oncology practices biannually, from January, 2015, to June, 2019. The primary outcome was whether reproductive risks were discussed before initiation of chemotherapy. Multivariate logistic regression was performed to identify factors associated with fertility preservation counseling, controlling for age, sex, race/ethnicity, cancer type, year of study, region, clinic type (academic vs private), annual clinic volume, and rates of insurance coverage. Among the 6976 patients of reproductive age (3571 men 51%; mean (SD) age, 42.5 7.1 years), with reproductive age ranging from 18 to 40 years for 3405 women and from 18 to 50 years for 3571 men, clinics reported that 3036 of 6976 patients (44%) received counseling regarding the risk of infertility associated with chemotherapy. Women were more likely to be informed (1912 of 3405 56%) compared with men (1126 of 3571 32%) (P < .001). Factors associated with reduced likelihood of fertility risk discussion included male sex (odds ratio OR, 0.73; 95% CI, 0.60-0.90), increasing age (OR, 0.93; 95% CI, 0.92-0.94), private practice setting (OR, 0.70; 95% CI, 0.53-0.93), and lack of multidisciplinary team planning (OR, 0.54; 95% CI, 0.41-0.70). Factors associated with increased likelihood of fertility risk discussion included having breast cancer (OR, 1.39; 95% CI, 1.12-1.73) and lymphatic or hematopoietic cancers (OR, 1.79; 95% CI, 1.33-2.40), participating in each subsequent study year (OR, 1.16; 95% CI, 1.08-1.24), receiving care in an academic clinic (OR, 1.45; 95% CI, 1.05-2.01), and being a practice offering clinical trial enrollment (OR, 1.60; 95% CI, 1.13-2.29). States with legislatively mandated coverage of fertility preservation had significantly higher rates of fertility risk discussion compared with states without legislation (48.6% vs 39.6%, P < .001). The findings suggest that clinicians are more likely to counsel younger patients and female patients about reproductive risks before initiation of chemotherapy. State laws mandating fertility preservation coverage may be associated with improved frequency of fertility counseling before chemotherapy. Further awareness and implementation of ASCO guidelines appear to be needed to improve rates of fertility risk discussion and referrals to fertility specialists before chemotherapy.