There is an increasing use of medical management for gynecologic cancers given the rise in neoadjuvant therapies, delayed childbearing, and use of assisted reproductive technology. Chemotherapy, albeit broadly used in most gynecologic cancers, lacks long term data with respect to its associated gonadotoxicity and potential adverse pregnancy outcomes. Immunotherapy and other targeted therapies that have demonstrated promising responses in other tumor types are increasingly being studied in gynecologic malignancies. These therapies may offer opportunities for enhanced treatment response in an effort to minimize more toxic, invasive, or surgical management approaches that could have significant negative implications on fertility. Given that some of these therapies do not represent the standard of care and currently only exist in the experimental setting, detailed counseling and careful selection of patients for fertility sparing treatment remains critical. It is reasonable for patients with early stage, low-risk endometrial cancers to attempt conservative management while establishing clear treatment objectives. Early involvement of fertility specialists is necessary in order to optimize these patients' pregnancy goals. An emphasis on lifestyle changes and in particular weight loss should also be discussed with these patients. Neoadjuvant chemotherapy followed by fertility sparing surgery in cervix cancer patients with low-risk, small tumors shows promising results that suggest this can be a safe treatment option. Patients with advanced stage disease of any primary tumor or aggressive histology such as in many cases of ovarian cancer are not appropriate candidates for prioritization of fertility sparing treatment options. Ongoing and future studies will help to better identify appropriate patients and maximize medical management options in early-stage gynecologic cancers.