The study of fusion reactions at extreme sub-barrier energies has seen an increased interest in recent years, although difficult to measure due to their very small cross sections. Such reactions are extremely important for our understanding of the production of heavy elements in various environments. In this article, the status of the field is reviewed covering the experimental techniques, the available data, and the theoretical approaches used to describe such reactions. The fusion hindrance effect, first discovered in medium-mass systems, has been found to be relevant also for lighter systems. In some light systems, resonance structures are found to be important, while for heavy systems, the fission process plays an important role. In the near barrier region, couplings to collective excitations in the fusion participants and transfer reactions have been found to give a good description of the measured fusion cross sections and it results in a distribution of fusion barrier heights. New physics ingredients, related to the overlap process of the two projectiles, have to be introduced to describe the hindrance behavior. In addition, it has recently been found that the fusion cross section in both near-barrier and sub-barrier regions can be described very well in many cases using simple, analytical forms of the barrier-height distributions or a modified version of the classic Wong formula.