Who needs to con­sider preser­va­tion of Fertility?

a. The Amer­i­can Can­cer Soci­ety esti­mates that 760,000 men will be diag­nosed with can­cer in 2009. Can­cer itself (before treat­ment) is some­times asso­ci­ated with less sperm pro­duc­tion in men. This is spe­cially the case in Hodgkin’s lym­phoma, tes­tic­u­lar can­cer, prostate can­cer, leukemias and colon can­cer. The most harm­ful fac­tor, how­ever, is can­cer treat­ment. Chemother­apy and radi­a­tion sig­nif­i­cantly impair sperm pro­duc­tion. The effect of chemother­apy depends on age, drug used, dose and dura­tion. Cyclophos­phamide appears to be the most harm­ful agent. Radi­a­tion also impairs sperm pro­duc­tion espe­cially at doses of 1200cGy or more.

Sperm count some­times recover to a vari­able extent years after can­cer treat­ment. This depends on the type of can­cer and treat­ment used. For exam­ple 90% of men diag­nosed with Hodgkin’s lym­phoma, treated with MOPP chemother­apy reg­i­men, do not have any sperm in the ejac­u­late after one year.

b. Bone mar­row trans­plan­ta­tion for can­cer of non­ma­lig­nant dis­eases usu­ally require prior irra­di­a­tion and chemother­apy. This is asso­ci­ated with high risk (85%) of com­plete fail­ure of sperm production.

c. Con­nec­tive tis­sue / autoim­mune dis­eases as lupus and rheuma­toid arthri­tis requir­ing treat­ment with chemotherapy.

d. Genetic abnor­mal­i­ties asso­ci­ated with rapid loss of male germ cells e.g. Kleine­fel­ter syn­drome, Y chro­mo­some microdele­tion (AZFc).

Meth­ods used for Fer­til­ity Preservation

Meth­ods used to pre­serve fer­til­ity in men are gen­er­ally divided into two categories:

Pro­tec­tion of the testes from dam­age caused by can­cer treatment:

1. Shield­ing the testes from radi­a­tion field.

2. Pro­tec­tion of the testes from the effect of chemotherapy.

GnRH ago­nists are a group of med­ica­tions that sup­press the mas­ter gland in the brain, pre­vent­ing the release of the hor­mones that stim­u­late sperm pro­duc­tion in the testes. Although sug­gested, there is no proof that they actu­ally increase the odds for preg­nancy after the use of chemother­apy. Actu­ally, there is no effec­tive pro­tec­tive med­ica­tion avail­able for use in men or women.

Low Tem­per­a­ture Stor­age of Sperm and Tes­tic­u­lar Tissue:

a. Sperm Cry­op­reser­va­tion. This is the stan­dard method for preser­va­tion of fer­til­ity in men. A sperm sam­ple is obtained by mas­tur­ba­tion and frozen for later use. If fea­si­ble mul­ti­ple sam­ples are obtained. In the future, sperm sam­ple are used for intrauter­ine insem­i­na­tion or IVF / intra­cy­to­plas­mic sperm injec­tion (ICSI). Bank­ing sperm was found to offer not only a chance to father chil­dren in the future but also encour­age­ment and improved morale dur­ing dis­ease treat­ment espe­cially if it was ini­ti­ated by the patient own initiative.

Lack of infor­ma­tion and coun­sel­ing is the most impor­tant rea­son why men diag­nosed with can­cer do not bank their sperm.

Although freez­ing may reduce the qual­ity of sperm espe­cially if it was not opti­mal before freez­ing, mod­ern repro­duc­tive med­i­cine can han­dle the major­ity of com­pro­mised spec­i­mens yield­ing excel­lent preg­nancy rates, sim­i­lar to those of fresh sperm.

b. Tes­tic­u­lar Sperm Extrac­tion (TESE). This sur­gi­cal pro­ce­dure retrieves sperm from inside the testes if no sperm was found in the ejac­u­late. If this pro­ce­dure is used before can­cer treat­ment, sperm are retrieved in over 50% of cases. Sperm or tes­tic­u­lar biop­sies are frozen for later use. ICSI is used for fer­til­iza­tion. In case of tes­tic­u­lar can­cer, sperm retrieval can be per­formed at the same time of surgery for cancer.

c. Tes­tic­u­lar Tis­sue or Germ Cell Freez­ing. This is an exper­i­men­tal tech­nique. Imma­ture germ cells or tes­tic­u­lar pieces are frozen for later trans­plan­ta­tion. No preg­nancy was achieved using this method so far.

In con­clu­sion, fertility-sparing strat­egy is read­ily avail­able to the major­ity of men at risk for dimin­ished fer­til­ity through sperm cry­op­reser­va­tion. Men inter­ested in father­ing chil­dren in the future should be coun­seled about this option. Read more at http://nycivf.org