Male Fertility Preservation

Male infertility is an inability to produce healthy sperm or to ejaculate sperm. Although sperm production usually recovers after cancer treatment, discuss the risks of infertility with your healthcare provider before cancer treatment begins. Sperm can be preserved and frozen for future use. However, if you have already started treatment, chemotherapy or radiation can cause genetic damage to sperm cells. Set up an appointment with a member of your health care team to discuss concerns or questions you may have. Ask for a referral to a fertility clinic or specialist.

Learning about infertility can cause stress. You may worry about the impact on your relationship or feel a loss of self-esteem. Talk with your health care provider if you think that the topic of infertility may be having an impact on your emotional well-being and consider whether a support group or some counseling could be helpful.

Cancers that Could Cause Male Infertility

Some types of cancer temporarily lower a man’s fertility. Infertility is most likely to happen before cancer treatment and just after treatment is finished. An initial analysis may show infertility, but the results could change over the next month or even years.

For those who will recover sperm production, semen analysis will usually improve within one to three years after finishing cancer treatment. However, some men improve many years later. Men should use effective means of birth control even if there is possibility of infertility.

Testicular cancer: Fertility may be poor during the two years before testicular cancer is discovered. Although only one to three percent of men with testicular cancer get cancer in both testicles, the cancer-free testicle may not function normally. On the other hand, men treated for testicular cancer often end up with improved semen quality within several years.

Newly-diagnosed Hodgkin’s disease, lymphoma or leukemia: Recent surgery, fever or physical stress experienced by survivors may affect the quality of semen.

Treatments that Could Cause Male Infertility

Cancer treatment, not cancer itself, is often what damages fertility. Here are some common treatments and their possible effects on fertility.

• Radiation therapy can slow down or stop sperm cell production if the testicle is in or near the target area for the radiation. A lead shield can help protect the testicles, but radiation “scatters” within the body, so it’s impossible to shield the testicles completely. Total body irradiation used before some bone marrow transplants often causes permanent infertility. If the testicles get a mild dose of radiation, a man’s fertility may drop but can then recover over the next one to four years. If the radiation dose to the testicles is high, sperm production may stop forever. Some boys treated for acute leukemia need to have radiation directly to the testicles. This can permanently damage their sperm production and hormones. Radiation damage to the part of the brain that controls hormone production can sometimes interfere with the hormone messages that control sperm production in the testicles.
• The alkylating chemotherapy group does the most damage to fertility. These drugs include cyclophosphamide (Cytoxan), chlorambucil (Leukeran), busulfan (Myleran), procarbazine (Natulan, Matulane), nitrosoureas (Carmustine, Lomustine), nitrogen mustard (Mustargen), and L-phenylalanine mustard (Alkeran). In high doses, platinum-based chemotherapy (Cisplatin, Oxaliplatin) or drugs like bleomycin (Blenoxane, Bleomycin), often used to treat testicular cancer, can also damage fertility.

• Surgery to treat prostate or bladder cancer removes the prostate and seminal vesicles. These glands make the liquid part of a man’s semen. They also cut the pathway for sperm cells to be included in the semen. Men with testicular cancer or colon cancer sometimes have surgery that can damage nerves involved in orgasm. The result may be a “dry orgasm” or the sensation of pleasure, but without ejaculating any semen.

A man is at higher risk for infertility if he gets two or more alkylating chemotherapy drugs, has higher doses of chemotherapy (for example before a stem cell or bone marrow transplant), or has a combination of chemotherapy and pelvic or whole-body radiation. High doses of chemotherapy can damage sperm cell production and the testicles’ ability to make testosterone. This hormone is crucial in a man’s fertility.

Fertility Testing

A semen analysis tests a man’s fertility. A sample is collected very soon after ejaculation and examined under a microscope. The analysis usually includes at least three scores that define semen quality:

• The sperm count is the number of sperm present. A normal count is at least 20 million sperm per milliliter of semen.
• The motility is the percentage of sperm that are actively swimming around. At least 50 percent of the sperm should be motile.
• The morphology is the shape of the sperm. It is considered normal if at least 30 percent of the sperm have an ideal shape. Some labs use a different (Kruger) scoring system which is stricter—only 14 percent of sperm cells need to have an ideal shape with this system.

Fertility Preservation Options

Sperm Banking

• How it works: Before beginning chemotherapy or radiation, a man produces a semen sample at a medical laboratory or sperm bank or from home. Masturbation is the preferred method, since even using a condom during intercourse could leave the semen contaminated with bacteria. Samples produced at home need to be kept at body temperature and delivered to the lab within an hour. Some sperm banks provide kits a man can use at home, mixing a preserving chemical with his semen and using overnight mail to the lab. A semen analysis is done. As long as the sample contains some live sperm cells, it can be frozen and stored for future use in infertility treatment. Once frozen, samples can be kept for at least 20 to 30 years (possibly longer) without further damage.
• Cost: Most health insurance plans do not cover the cost of storing frozen semen. They also may not pay for the semen analysis if it is known to be part of the banking process. Many sperm banks have monthly payment plans to make banking more affordable.
• Who can do it: Males who have reached puberty (even as young as age 12 or 13) can bank sperm for as long as the semen contains enough live and healthy sperm.
• Where to bank sperm: Most large cities have sperm banks that can be found on the internet. A member of your oncology health care team should also be able to give you a referral. Many sperm banks will work with a local laboratory to process your sample and send it for analysis and long-term storage.

Freezing Tissue From the Testicle

• How it works: If a boy is too young to produce sperm cells but will have a high risk of infertility after his cancer treatment, an experimental option is to put him under anesthesia for an outpatient surgery, remove several areas of tissue from his testicles, and freeze that tissue for future use. Once he is an adult and free of cancer, if he is indeed infertile, he could use the tissue in one of several ways. None of these methods has yet produced the birth of a live baby, however. The tissue pieces could be thawed and put back into his testicle in the hopes that they would begin to produce sperm. This is a delicate process that would only work if his hormones were normal and his testicles were at a good temperature with a good supply of blood circulation.
• Who Can Do It: Only a few infertility and cancer centers offer testicular tissue freezing. Most boys who have cancer treatment do not try to preserve their fertility. Until tissue freezing produces successful births, it should be offered as a research option, with the parents signing an informed consent form. Some research programs have funds to cover the costs of getting and storing the tissue, which is important since the procedure is expensive and may never be helpful.

In Vitro Fertilization – Intracytoplasmic Sperm Injection (IVF-ICSI)

When less than two million sperm cells are available for infertility treatment, the usual choice is to use them in In Vitro Fertilization with Intracytoplasmic Sperm Injection (IVF-ICSI).

• How it works: The woman who will carry the child must undergo hormone shots for several weeks to stimulate her ovaries to ripen more than one or two eggs. The woman’s eggs are harvested or collected through a minor outpatient surgery. The harvested eggs are cleaned in the laboratory and stored in individual dishes to be ready for fertilization. The embryologist uses a special microscope to choose a healthy-looking sperm and injects it into an egg. If all goes well, several embryos can be created. Usually just one or two embryos are placed into the uterus of the female partner in the hopes that they will implant and start a pregnancy.
• Cost: IVF-ICSI is expensive and involves some medical risks for the woman. However, it’s also successful, especially if the woman has normal fertility and is younger than 35.
• Who can do it: Since only a few sperm are needed, IVF-ICSI is a good option for men who have poor semen quality or have sperm with poor motility.

Intrauterine Insemination (IUI)

This option is for men with semen quality that is closer to normal.

• How it works: A man’s semen sample is purified and concentrated to contain as many active sperm as possible. In a health care provider’s office, the sample is put in a thin catheter (tube) and slipped directly through the woman’s cervix into her uterus to give the sperm a head start on fertilizing the egg. The procedure is done at a woman’s midcycle, her fertile time of month. Sometimes the woman is given extra hormones to ripen more than one egg, but not in the high doses used in IVF. This is called superovulation. If an ultrasound shows that too many eggs are ripening, the insemination should either be canceled or the woman should have her eggs gathered and used for IVF instead. Otherwise there is a high risk of a multiple pregnancy, with all of its dangers for the mother and infants.

Family Building Options

Donor Insemination

• How it works: A man donates his sperm. The survivor may choose someone that is known personally or much more commonly, the man or couples chooses a sperm donor who has worked with a donor sperm from a sperm bank. may be used. The donor may be similar to the man in ethnic background, coloring, etc. Most sperm donors in the United States prefer to remain anonymous, but many give the bank information about their hobbies and personalities. Their family and personal health histories are analyzed carefully to minimize the chance of an inherited disease. The semen is used as in IUI to create a pregnancy.

Adoption

• How it works: Adoption is accepting legal responsibility for an orphaned child. Contact an adoption agency for more information. Adoption has become difficult as more young, single women keep their babies. Many international countries will not allow a cancer survivor to adopt, but some will accept a letter from the oncologist stating that the survivor is healthy, with a normal expected life span. Most adoptions in the United States are independent, arranged by an attorney. Birth mothers often choose the adoptive parents from many “profiles” they receive. Domestic agencies vary in how open they are to working with cancer survivors.
• Cost: The process can be expensive ($5,000 to $40,000) and may take a long time.
• Who can do it: Adoption agencies have screening processes for anyone who wants to adopt. Talk with your health care team about getting any documentation that may be needed to confirm that you are healthy and able to care for a child.