Advances in cancer treatment have improved survival rates for many patients with pelvic malignancies, highlighting the importance of long-term reproductive outcomes and overall quality of life. Pelvic radiotherapy, chemotherapy, and multimodal treatment can cause substantial and permanent injury to ovarian reserve, uterine function, or both. Oncofertility can be clinically complex because reproductive risks and available options vary according to patient age, pubertal status, cancer type, treatment urgency, planned radiotherapy field, chemotherapy regimen and dosage, baseline ovarian reserve, desire for future pregnancy, and expertise. The present review summarizes established and emerging fertility preservation options for patients undergoing treatment for pelvic malignancies. Cryopreservation focused options, including embryo, oocyte, and ovarian tissue cryopreservation, can preserve gametes, embryos, or ovarian tissue before gonadotoxic therapy but do not protect the uterus from radiation related injury. Surgical approaches, including ovarian transposition, uterine ventrofixation, and uterine transposition, are aimed at reducing radiation exposure to reproductive organs, although their effectiveness depends on surgical technique, radiation planning, and use of systemic therapy. Uterine transplantation may provide a restorative option for selected patients with irreversible uterine factor infertility but remains highly specialized and resource intensive. Because each option differs in timing, evidence base, risks, costs, resource requirements, and applicability across patient groups, fertility preservation should be discussed early and incorporated into multidisciplinary cancer care. Continued research is needed to better define reproductive outcomes, pregnancy safety, complications, and comparative effectiveness of emerging approaches.