SEMEN QUALITY AND REPRODUCTIVE HORMONES BEFORE AND AFTER ORCHIECTOMY IN MEN WITH TESTICULAR CANCER

The effects of cancer and cancer treatments on male reproductive function

In male cancer patients, surgery, radiotherapy and chemotherapy can be followed by transient or permanent infertility by affecting ejaculatory or erectile function, or by impairing spermatogenesis. Cancer specialists should, therefore, discuss the impact of different therapies on fertility with their patients prior to treatment, and consider fertility-preserving measures before and during treatment, such as nerve-sparing operative techniques, adequate testicular shielding during radiotherapy and the avoidance of unnecessary gonadotoxic chemotherapy. Pretreatment sperm-cell cryopreservation should be offered, even in cases where the individual's risk of post-treatment infertility might seem minimal or if it might require testicular sperm-cell extraction. Samples that are severely oligospermic should also be cryopreserved. Post-treatment ejaculatory or erectile dysfunction can be reversed pharmacologically, but the success rate varies with the extent of neurologic sequelae of the treatments used. At present there is no established method to stimulate post-treatment impaired spermatogenesis, although currently available assisted reproductive techniques overcome some of the existing problems of infertility in cancer survivors, and ongoing research will hopefully increase these possibilities. A multidisciplinary approach that depends on close cooperation between relevant medical specialists is central to achieving such advances.

Quality of life in survivors of testicular cancer

The objective of this review was to give an overview of findings concerning quality of life (QOL) in general as well as its domains in survivors of testicular cancer. QOL on the group level was equal to that of men of the same age in the general population. Treatment strategies hardly influenced the QOL. The anxiety level, but not depression, was higher among survivors, while sexual functioning hardly differed from the male population norm. Patients to be treated for testicular cancer should be told about the outlook for good QOL, and the low risk of mental and physical long-term effects.

The Metabolic Syndrome and Disturbances in Hormone Levels in Long-Term Survivors of Disseminated Testicular Cancer

Purpose

The metabolic syndrome may be an important risk factor for cardiovascular disease in long-term survivors of testicular cancer (TC). We investigated the associations between hormone levels and the metabolic syndrome in these men.

Patients and Methods

We included TC patients cured by orchidectomy and cisplatin-based chemotherapy, stage I TC patients after orchidectomy only, and healthy men of comparable age. Presence of the metabolic syndrome was determined using guidelines from the National Cholesterol Education Program Adult Treatment Panel III. Thyroid-stimulating hormone, follicle-stimulating hormone (FSH), inhibin B, luteinizing hormone (LH), total testosterone, sex-hormone–binding globulin, free testosterone, estradiol, dehydroepiandrosterone sulfate, and insulin-like growth factor 1 were determined in blood. Cortisol metabolite excretion was measured in urine.

Results

Eighty-six chemotherapy patients (median follow-up, 7 years) were compared with 44 stage I patients and 47 controls. LH and FSH were higher, and inhibin B and total and free testosterone were lower in chemotherapy patients than controls. Adrenal and thyroid hormone production were unaffected. Chemotherapy patients with the metabolic syndrome (n = 22; 26%) had a higher body mass index (BMI) pretreatment, a larger BMI increase during follow-up, lower total testosterone, and higher urinary cortisol metabolite excretion than those patients without the metabolic syndrome. BMI and insulin were associated with the metabolic syndrome, while total testosterone and urinary cortisol metabolite excretion were associated with BMI.

Conclusion

We found gonadal dysfunction, but normal adrenal and thyroid function. Through its association with BMI, testosterone may play a role in the development of the metabolic syndrome in long-term TC survivors.

[Diagnosis and primary treatment of testicular tumor]

In cases of suspected testicular germ cell cancer, the first diagnostic steps include scrotal sonography, ultrasound of the retroperitoneum and abdomen, determination of serum tumor markers (AFP, betaHCG, LDH), and inguinal orchiectomy with contralateral scrotal testicular biopsy. Histology of the orchiectomized testis is essential for the patient's further treatment options. For synchronous or metachronous bilateral testis cancer or germ cell cancer in a single testis, organ-sparing surgery with resection of the (small) tumor (<2 cm) is possible. After these initial steps, further diagnostic procedures include computed tomography of the abdomen/pelvis and lung. In cases of hematogeneous spread of the disease, bone scan and CT or MR of the brain are performed additionally. The determination of serum tumor markers after orchiectomy is mandatory. Treatment of testicular cancer is based on exact knowledge of the histological type and stage of the disease. In metastatic testis cancer treatment modalities are defined according to the prognosis of the tumor (defined by the IGCCCG). In cases of testicular intraepithelial neoplasia (TIN) of the contralateral testis or in residual testicular tissue after tumor enucleation, three available treatment options can be discussed with the patient: orchiectomy, radiotherapy, or surveillance. The decision depends on the individual situation of the patient. Radiotherapy with 20 Gy is accepted as standard treatment. In general, treatment of testis cancer is associated with gonadal toxicity. Therefore, prior to further treatment, aspects of family planning, wish for children, and the option to cryopreserve semen (in cases of azoospermia cryopreservation of testicular tissue) have to be discussed.

Normal semen parameters in cancer patients presenting for cryopreservation before gonadotoxic therapy

Similar sperm qualities in men with and without cancer were found. Patient and physician awareness and early referral for sperm banking are essential in preserving fertility potential in men with malignancies.

Fecundity and Twinning Rates as Measures of Fertility Before Diagnosis of Germ-Cell Testicular Cancer

Previous studies have suggested an association between subfertility and testicular cancer by using fecundity and semen characteristics to measure fertility. The occurrence of twinning in offspring may be used to investigate male reproductive health, because dizygotic twinning is reduced by male subfertility. We therefore assessed number of children and offspring twinning rates among 4592 Swedish patients with testicular cancer and 12 254 control subjects. Before diagnosis, case patients had a decreased number of children (for testicular cancer, odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.62 to 0.81; at least three children compared with no children), with a lower frequency of dizygotic twinning (for unlike-sex twins, OR for the father having testicular cancer = 0.49, 95% CI = 0.22 to 1.08). The ratio of unlike-sex to same-sex twins was 0.22 among children of case patients and 0.66 among children of control subjects (adjusted P =.03, two-sided Wald test). We also found an increased occurrence of twinning after diagnosis, probably attributable to treatment for iatrogenic subfertility. Our study strongly supports evidence of an association between subfertility and the subsequent risk for testicular cancer.

Increased Risk of Carcinoma In Situ In Patients With Testicular Germ Cell Cancer With Ultrasonic Microlithiasis In the Contralateral Testicle

PURPOSE

We compared clinical and histological data regarding the contralateral testicle in a population of men diagnosed with testicular germ cell cancer to find features associated with an increased risk of bilateral neoplasia.

MATERIALS AND METHODS

Clinical data obtained from the records of 79 men seen during the period 1998 to 2001 included history, physical and ultrasound examination, and the results of semen and hormonal analysis. Contralateral testicular biopsies were obtained from all men and analyzed for carcinoma in situ (CIS), microcalcifications (microliths) and other signs of testicular dysgenesis.

RESULTS

Ultrasound examination of the contralateral testicle was performed in 64 of the cases. The echo pattern was judged normal in 30 cases, slightly irregular in 22, irregular in 3 and showed microlithiasis in 9. The frequency of microlithiasis seen on ultrasound was significantly higher among patients with CIS (p <0.001) compared to those with a normal echo pattern (Fisher's exact test). The overall frequency of reported cryptorchidism was 18.7% with no difference in seminoma and nonseminoma distribution between patients with or without a history of cryptorchidism. The median age of patients with cryptorchidism, 25.8 years (range 15.8 to 31.7), was significantly younger (the Mann-Whitney test p <0.05) than the age of those with normal testicular descent, 31.4 years (range 17.8 to 52.9).

CONCLUSIONS

The finding of contralateral testicular microlithiasis on ultrasound in a patient with testicular germ cell cancer increases the risk of harboring carcinoma in situ in that testicle (odds ratio 28.6; CI: 4.8-170.4). Conversely, a normal ultrasound pattern does not exclude the risk of CIS. Whether sonographic microlithiasis found in other subgroups of patients or in men from the general population also implies an increased risk of testicular CIS remains to be clarified.

Endocrine function in patients treated for carcinoma in situ in the testis with irradiation

CIS is found in the contralateral testis in 5% of the patients with testicular germ cell cancer. The management of CIS in the contralateral testis is important because the majority - if not all - cases of CIS will progress to invasive disease without treatment. It is well documented that testicular irradiation with a total dose of 14-20 Gy (2 Gy x 7-10) is an effective and safe treatment for CIS in the contralateral testis in patients with unilateral testicular germ cell cancer. However few relapses of testicular cancer have been observed in testis treated with these regimens and the data on 14 Gy are sparse. One study has indicated that more radiotherapy with lower doses per fraction could be useful, but more data are needed to confirm this. Endocrine testicular function has been shown to be impaired already before treatment in patients with CIS and is further impaired after testicular irradiation with 14-20 Gy (2 Gy x 7-10) and only minor dose dependency is seen in the impairment of Leydig cell function. The optimal treatment of CIS in the contralateral testicle in patients orchidectomised for testicular cancer seems to be local radiotherapy of the testis with CIS in order to preserve at least a part of the Leydig cell function. However, the optimal dose level has to be defined.

Gonadal function in patients with testicular germ cell tumors

The gonadal function of 18 patients with testicular germ cell tumors was evaluated. Seminal parameters after orchiectomy were examined in 15 patients. Six of them were available for follow-up observation after 2 or 3 courses of adjuvant chemotherapy. Serum gonadal hormones before and after orchiectomy were evaluated in 7 patients (testosterone and PRL were not examined in one patient). Five of 15 (33.3%), 8 of 15 (53.3%), 13 of 15 (86.7%), 7 of 13 (53.8%), and 9 of 12 (75.0%) had abnormal values in seminal volume, sperm concentration, motility, morphology, and vitality, respectively. The sperm concentration gradually improved after chemotherapy following orchiectomy in 5 of 6 (83.3%) patients. In all the patients examined, serum levels of follicular stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) increased after orchiectomy. Serum levels of testosterone increased in 4 patients, but decreased in 2 after orchiectomy. These findings suggest that several factors, including preexisting intrinsic defect and disturbance of the hypothalamus-pituitary-gonadal axis, are involved in the deterioration of gonadal function in patients with testicular germ cell tumors.

Effect of graded testicular doses of radiotherapy in patients treated for carcinoma-in-situ in the testis

PURPOSE

To determine the effect of radiotherapy in doses 14 to 20 Gy on eradication of carcinoma-in-situ (CIS) testis and on the Leydig cell function.

PATIENTS AND METHODS

Forty-eight patients presented with unilateral testicular germ cell cancer and CIS of the contralateral testis. The CIS-bearing testis was treated with daily irradiation doses of 2 Gy, 5 days a week, to a cumulative dose of 20 Gy (21 patients), 18 Gy (three patients), 16 Gy (10 patients), and 14 Gy (14 patients).

RESULTS

All patients treated at dose levels 20 Gy to 16 Gy achieved histologically verified complete remission without signs of recurrence of CIS after an observation period of more than 5 years. One of 14 patients treated at dose level 14 Gy had a relapse of CIS 20 months after irradiation. Leydig cell function was examined before and regularly after radiotherapy in 44 of 48 patients. The levels of testosterone were lower after radiotherapy than before. Testosterone showed a stable decrease for more than 5 years after treatment (3.6% per year) without dose dependency. The levels of luteinizing hormone and follicle-stimulating hormone were increased after radiotherapy. The need of androgen substitution therapy was similar at all dose levels.

CONCLUSION

Testicular irradiation is a safe treatment at dose level 20 Gy (10 x 2 Gy). Decrease of dose to 14 Gy (7 x 2 Gy) might lead to risk of relapse of CIS. Impairment of hormone production without clinically significant dose dependency is seen in the dose range 14 to 20 Gy.

The functional significance of FSH in spermatogenesis and the control of its secretion in male primates

The aim of this review is to provide an integrative analysis of the role of FSH in the control of testicular function in higher primates, including man. Attention is focused on the action of FSH during neonatal development, puberty, and adulthood. Whether FSH is the major determinant of the adult complement of Sertoli cells and whether FSH is obligatory for the initiation, maintenance, and restoration of spermatogenesis is evaluated. The mechanism whereby the circulating concentration of FSH regulates spermatogonial proliferation to dictate the sperm production rate under physiological conditions in the adult is discussed in detail. Inhibin B is the major component of the testicular negative feedback signal governing FSH beta gene expression and FSH secretion, and the evidence for this view is presented. The review concludes with the presentation of a model for the operation of the FSH-inhibin B feedback control system regulating sperm production postpubertally in monkey and man, and with speculation on issues of clinical interest.

The impact of chemotherapy on Leydig cell function in long term survivors of germ cell tumors

BACKGROUND

Because patients with germ cell tumors expect an additional life span of around 50 years after successful treatment, attention is now focused on potential long term toxicity. Limited data are available on Leydig cell function in long term survivors.

METHODS

The authors measured testosterone, sex hormone binding-globulin (SHBG), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels in 244 patients with germ cell tumors. Patients were divided into three groups: Group 1 had received no chemotherapy (n = 58 patients), Group 2 had received cumulative doses of cisplatin < or = 400 mg/m(2) (n = 117 patients), and Group 3 had received cumulative doses of cisplatin > 400 mg/m(2) (n = 69 patients). The median times from chemotherapy were 74 months and 75 months in Groups 2 and 3, respectively.

RESULTS

Subnormal testosterone levels (< 10 nmol/L) were found in 5%, 11%, and 20% in Groups 1, 2, and 3, respectively (Group 1 vs. Group 3; P = 0.02). The mean testosterone level and the testosterone/SHBG ratio did not differ significantly between Groups 1 and 2; however, they did differ between Groups 1 and 3 (testosterone: 17.0 nmol/L vs. 14.9 nmol/L, respectively; P = 0.02; testosterone/SHBG ratio: 0.70 vs. 0.59; P < 0.05). There was a significant inverse correlation between the testosterone/SHBG ratio and LH (correlation coefficient [r] = -0.25; P = 0.0002). A significant positive correlation was found for LH and FSH (r = 0.78; P < 0.0001), indicating a strong association between Leydig cell dysfunction and germinal epithelial damage.

CONCLUSIONS

Standard doses of cisplatin-based chemotherapy do not lead to a significant deterioration of Leydig cell function in long term survivors of germ cell tumors. In contrast, high cumulative doses of chemotherapy cause a significant and persistent impairment of Leydig cell function. More data are needed regarding the clinical relevance of moderate testosterone deficiency. Further research is necessary to determine whether some patients may benefit from testosterone replacement.

Fertility and sexual function following orchiectomy and 2 cycles of chemotherapy for stage I high risk nonseminomatous germ cell cancer

PURPOSE

We investigate fertility and sexual function in patients following orchiectomy and adjuvant cisplatin based chemotherapy for high risk, stage I nonseminomatous germ cell tumor of the testis.

MATERIALS AND METHODS

Between 1985 and 1994, 59 patients with stage I nonseminomatous germ cell tumor and poor prognostic factors were treated with 2 cycles of cisplatin, vinblastine and bleomycin, or bleomycin, etoposide and cisplatin after orchiectomy. At least 32 months following treatment all patients were contacted and asked to complete a questionnaire regarding fertility and sexual activity, and to volunteer for a semen and hormonal analysis.

RESULTS

Of the 59 patients 49 (83%) completed the questionnaire. Before chemotherapy 18 (37%) patients had fathered children, 6 (12%) were involuntarily childless and none had a major sexual dysfunction. After treatment 11 (22%) patients fathered children, and 5 (10%) were involuntarily childless, with 4 involuntarily childless before chemotherapy. There were no significant alterations in sexual function. Semen analysis in 27 patients was normal in 23, and revealed mild oligospermia in 2 and azoospermia in 2. In 18 patients with hormone analysis median values for luteinizing hormone and free testosterone were normal but median value for follicle-stimulating hormone was slightly increased.

CONCLUSIONS

Two cycles of cisplatin based adjuvant chemotherapy do not seem to affect adversely fertility or sexual activity.

Effects of cancer and anti-neoplastic treatment on the human testicular function

Men with testicular neoplasia (TN) and Hodgkin's disease (HD) are those who more frequently require treatment for fertility because these malignancies affect patients during the reproductive age and because the early diagnosis and the improved anti-neoplastic treatments cure most of these patients. Although some of them can father a child spontaneously, assisted reproductive techniques allow fatherhood to patients with severe spermatogenesis impairment and this possibility has raised concern about the long-term consequence of the testicular damage induced by chemo- and/or radiotherapy. This paper reviews the effects of cancer per se and of anti-neoplastic treatments on gonadal function, sperm aneuploidy rate and sperm DNA integrity. A debate is still open as to whether TN or HD per se may impair spermatogenesis. Many studies have shown that this is the case, albeit others have challenged this view. Chemo- and/or radiotherapy affects negatively gonadal function, rendering almost all patients azoospermics. However, spontaneous pregnancies and a high degree of spermatogenesis recovery occur with time. A large body of literature on sperm chromosome complement suggests an increased rate of structural and numerical chromosome abnormalities in patients with cancer during anti-neoplastic treatment. A minority of them has, however, shown that this effect disappears with time. An interesting and relatively new aspect is the study of sperm DNA integrity in patients with TN and HD particularly following chemo- and/or radiotherapy. The scanty information available seems to suggest that these patients have a permanent or at least a long-lasting DNA fragmentation in their spermatozoa.

Sexual function and fertility after treatment of testicular cancer

As a result of the introduction of effective cisplatin-based chemotherapeutic regimens into the clinical routine, even patients with metastatic testicular cancer at initial diagnosis can be cured of their disease. Sexual dysfunction and infertility are common long-lasting sequelae in testicular cancer survivors, affecting approximately 20% of patients after the application of the different treatment modalities currently available for the treatment of early and advanced clinical stages, including retroperitoneal surgery and systemic chemotherapy. Accordingly, it has been demonstrated that fertility distress and sexual disturbances, the latter occurring in only a minority of patients after surgical or chemotherapeutic treatment of testicular germ cell tumours, substantially alter the patients' quality of life. It is even worse because testicular cancer mostly affects men in the prime of their physical, sexual and reproductive function. Although semen quality is frequently poor at initial diagnosis and further deteriorates after orchiectomy, probably because of structural abnormalities in the remaining contralateral testicle, the advent of intracytoplasmatic sperm injection promises a fertile future to most patients, even if only a few sperms are present in the ejaculate. Further long-term investigations should be initiated to clarify the impact of the different treatment modalities on fertility and sexual life. The main objective should be the identification of patients who are at increased risk of developing therapy-related physical and psychological problems.

Cancer and male infertility

An increasing proportion of boys and young men with cancer will survive their disease and desire fertility. Unfortunately, the cancer treatment, and in some cases the malignant disease itself, may have a negative and permanent impact on the individual's fertility potential. This effect is highly dependent on the type and dose of therapy as well as the age at which it has been given. Basic knowledge in this field is necessary to enable oncologists and fertility specialists to counsel these patients about their fertility prospects and, if appropriate, advise them to take precautions (e.g. the cryopreservation of semen) to safeguard their fertility. Another aspect of the relationship between cancer and infertility is the possibility that men with testicular dysfunction may have an increased risk of testicular cancer. Screening for early testicular malignancy may therefore be advisable in some groups of men with poor semen quality.

Dynamics of the follicle-stimulating hormone (FSH)-inhibin B feedback loop and its role in regulating spermatogenesis in the adult male rhesus monkey (Macaca mulatta) as revealed by unilateral orchidectomy

The purpose of this study was to document the morphological changes in the seminiferous epithelium that underlie the compensatory testicular hypertrophy observed in response to unilateral orchidectomy (UO) in the adult rhesus monkey and to describe the concomitant response in the endocrine feedback loops controlling testicular function in this species. Adult male monkeys were implanted with indwelling venous catheters; seven animals were then subjected to UO (data are presented from six) and three to sham UO. Profiles of circulating concentrations of FSH, LH, testosterone (T), inhibin B, and pro-alpha-C were monitored in 12-h series of sequential blood samples collected before, on the day of UO (day 0), and on days 1, 2, 4, 8, 16, 32, and 42 or 43 after UO. In the UO monkeys, the remaining testis was taken on day 44. Sertoli and germ cells in the removed and remaining testes were counted and expressed either as number per testis or, in the case of the differentiated spermatogonia (B1, B2, B3, and B4), as number per cross-section of the seminiferous tubule. UO was associated with a marked increase in the number of all germ cells more mature than undifferentiated spermatogonia (Ap) in the remaining testis. Sertoli cell number, on the other hand, did not change, and it is therefore reasonable to propose that the primary locus of the spermatogenic compensation was the differentiated spermatogonia. The additional finding that the relationship between the number of Sertoli cells and total germ cells in the remaining testis became robust (r = 0.92; P < 0.01 vs. r = 0.44; P > 0.05 for the removed testis) indicated that in the monkey, spermatogenesis does not normally operate at its ceiling. The increased drive to the seminiferous tubule of the remaining testis is hypothesized to be mediated by the sustained increase in FSH secretion that was observed after UO, although a role for increased testicular T production cannot be excluded. The stimulus for increased FSH secretion was presumably provided by the abrupt, 50% decline in circulating inhibin B levels. Interestingly, inhibin B secretion by the remaining testis was not dramatically affected by UO, and therefore, the deficit in circulating levels of this hormone and thus the error signal to FSH secretion were maintained for the duration of the experiment. In contrast, the changes in circulating LH and T concentrations were only transient, and within 48 h of UO, these hormonal parameters had returned to control values. The mechanisms by which the remaining testis rapidly acquires the capacity to double T production in the face of an unchanging LH drive remains to be determined. The foregoing body of evidence suggests that sperm output by the monkey testis is regulated by the circulating concentration of FSH and that in physiological situations, FSH secretion is insufficient to stimulate spermatogenesis to its ceiling. The results also indicate that FSH secretion is controlled by a feedback system in which the feedforward arm (FSH-inhibin B) is less robust than the feedback loop (inhibin B-FSH). Thus, a decrease in the inhibin B feedback signal results in a sustained increase in FSH secretion that drives the testes toward their spermatogenic ceiling, which is presumably set by Sertoli cell number.

Semen cryopreservation after orchidectomy in men with testicular cancer

OBJECTIVE

To assess the feasibility of semen cryopreservation after orchidectomy in patients with testicular tumour.

PATIENTS AND METHODS

The quality of semen samples was investigated in 36 men with testicular tumour (mean age 31.7 years, range 20-49) who were referred to our infertility centre for semen cryopreservation. For each patient, the number of straws, semen volume, number of spermatozoa, and sperm motility before and after freezing were evaluated.

RESULTS

Fifteen patients (42%) banked sperm before and 21 (58%) after orchidectomy; the delay was >7 days in 19 patients (53%). The mean age, histological diagnosis and tumour stage did not differ significantly whatever the time of cryopreservation. Semen quality did not differ significantly in patients who cryopreserved sperm before or after orchidectomy and there were no significant differences in sperm values whatever the delay before preservation. Semen quality was the same in patients with seminoma or nonseminoma tumour.

CONCLUSION

These findings indicate that spermatogenesis of the contralateral testis is sufficient for successful semen cryopreservation after orchidectomy. Urologists should be encouraged to increase the awareness among oncology teams and patients about the new developments in preserving fertility for patients with cancer.

Pharmacological treatment of erectile dysfunction

There is growing evidence that the field of pharmacotherapy, particularly oral drugs, will be dominant in the future management of sexual dysfunction. Basic research has led to the understanding of the intracellular mechanisms that control penile smooth muscle contractility and therefore erection, opening a vast area for pharmacological intervention. Moreover, the importance of central neurohormonal mechanisms has made these pathways the target for new centrally acting drugs. Given these trends most patients suffering from erectile dysfunction will respond to pharmacological agents in the not so distant future.