[Reversible germ cell toxicity following aggressive chemotherapy in patients with testicular tumors: results of a prospective study]

Leydig cells contribute to the inhibition of spermatogonial differentiation after irradiation of the rat

Irradiation with 6 Gy produces a complete block of spermatogonial differentiation in LBNF1 rats that would be permanent without treatment. Subsequent suppression of gonadotropins and testosterone (T) restores differentiation to the spermatocyte stage; however, this process requires 6 weeks. We evaluated the role of Leydig cells (LCs) in maintenance of the block in spermatogonial differentiation after exposure to radiation by specifically eliminating functional LCs with ethane dimethane sulfonate (EDS). EDS (but not another alkylating agent), given at 10 weeks after irradiation, induced spermatogonial differentiation in 24% of seminiferous tubules 2 weeks later. However, differentiation became blocked again at 4 weeks as LCs recovered. When EDS was followed by treatment with GnRH antagonist and flutamide, sustained spermatogonial differentiation was induced in >70% of tubules within 2 weeks. When EDS was followed by GnRH antagonist plus exogenous T, which also inhibits LC recovery but restores follicle stimulating hormone (FSH) levels, the spermatogonial differentiation was again rapid but transient. These results confirm that the factors that block spermatogonial differentiation are indirectly regulated by T, and probably FSH, and that adult and possibly immature LCs contribute to the production of such inhibitory factors. We tested whether insulin-like 3 (INSL3), a LC-produced protein whose expression correlated with the block in spermatogonial differentiation, was indeed responsible for the block by injecting synthetic INSL3 into the testes and knocking down its expression in vivo with siRNA. Neither treatment had any effect on spermatogonial differentiation. The Leydig cell products that contribute to the inhibition of spermatogonial differentiation in irradiated rats remain to be elucidated.

Gonadotropin-Releasing Hormone Antagonist (Cetrorelix) Therapy Fails to Protect Nonhuman Primates (Macaca arctoides) From Radiation-Induced Spermatogenic Failure

Treatment of men of reproductive age with radiation or alkylating agents often produces prolonged azoospermia. We previously demonstrated that suppression of testosterone (T) with gonadotropin-releasing hormone (GnRH) analogs restored spermatogenesis following atrophy induced by radiation or chemotherapy in rats. This study tested whether GnRH antagonist therapy could reverse radiation-induced testicular injury in primates with a similar protocol. Adult male stump-tailed macaques were given either 6.7 Gy radiation to the testis alone, 6.7 Gy radiation combined with GnRH-antagonist treatment starting on the day of exposure, or daily injections of the GnRH antagonist Cetrorelix for 3 months alone and were monitored for 18 months. Cetrorelix alone produced a 20-40-week fully reversible suppression of serum T, but although spermatogenic recovery was incomplete, 40%-90% of tubules contained differentiating germ cells. Following radiation alone, testis volumes were reduced to approximately 28% and sperm counts to less than 1% of pretreatment values. A biopsy at 18 months after radiation showed that only 3.0% of seminiferous tubule cross sections had germ cells. In irradiated animals that received GnRH antagonist, testis volumes were reduced to 18% of pretreatment volume, and at 18 months, only 1.9% of seminiferous tubule cross sections contained germ cells. Inhibin B values were reduced to 10% and 3% of pretreatment levels in the radiation-only and the radiation plus GnRH antagonist groups, respectively. Species differences exist in the testicular response to radiation, GnRH antagonist therapy, or both, so that rescue protocols that were successful in rodents might not work in primates.

Hormonal suppression restores fertility in irradiated mice from both endogenous and donor-derived stem spermatogonia

Irradiation interrupts spermatogenesis and causes prolonged sterility in male mammals. Hormonal suppression treatment with gonadotropin-releasing hormone (GnRH) analogues has restored spermatogenesis in irradiated rats, but similar attempts were unsuccessful in irradiated mice, monkeys, and humans. In this study, we tested a stronger hormonal suppression regimen (the GnRH antagonist, acyline, and plus flutamide) for efficacy both in restoring endogenous spermatogenesis and in enhancing colonization of transplanted stem spermatogonia in mouse testes irradiated with a total doses between 10.5 and 13.5 Gy. A 4-week hormonal suppression treatment, given immediately after irradiation, increased endogenous spermatogenic recovery 1.5-fold, and 11-week hormonal suppression produced twofold increases compared with sham-treated irradiated controls. Furthermore, 10-week hormonal suppression restored fertility from endogenous surviving spermatogonial stem cells in 90% of 10.5-Gy irradiated mice, whereas only 10% were fertile without hormonal suppression. Four- and 11-week hormonal suppression also enhanced spermatogenic development from transplanted stem spermatogonia in irradiated recipient mice, by 3.1- and 4.8-fold, respectively, compared with those not given hormonal treatment. Moreover, the 10-week hormonal suppression regimen, but not a sham treatment, restored fertility of some 13.5-Gy irradiated recipient mice from donor-derived spermatogonial stem cells. This is the first report of hormonal suppression inducing recovery of endogenous spermatogenesis and fertility in a mouse model treated with anticancer agents. The combination of spermatogonial transplantation with hormonal suppression should be investigated as a treatment to restore fertility in young men after cytotoxic cancer therapy.

Gene expression profiles of mouse spermatogenesis during recovery from irradiation

BACKGROUND

Irradiation or chemotherapy that suspend normal spermatogenesis is commonly used to treat various cancers. Fortunately, spermatogenesis in many cases can be restored after such treatments but knowledge is limited about the re-initiation process. Earlier studies have described the cellular changes that happen during recovery from irradiation by means of histology. We have earlier generated gene expression profiles during induction of spermatogenesis in mouse postnatal developing testes and found a correlation between profiles and the expressing cell types. The aim of the present work was to utilize the link between expression profile and cell types to follow the cellular changes that occur during post-irradiation recovery of spermatogenesis in order to describe recovery by means of gene expression.

METHODS

Adult mouse testes were subjected to irradiation with 1 Gy or a fractionated radiation of two times 1 Gy. Testes were sampled every third or fourth day to follow the recovery of spermatogenesis and gene expression profiles generated by means of differential display RT-PCR. In situ hybridization was in addition performed to verify cell-type specific gene expression patterns.

RESULTS

Irradiation of mice testis created a gap in spermatogenesis, which was initiated by loss of A1 to B-spermatogonia and lasted for approximately 10 days. Irradiation with 2 times 1 Gy showed a more pronounced effect on germ cell elimination than with 1 Gy, but spermatogenesis was in both cases completely reconstituted 42 days after irradiation. Comparison of expression profiles indicated that the cellular reconstitution appeared equivalent to what is observed during induction of normal spermatogenesis.

CONCLUSION

The data indicates that recovery of spermatogenesis can be monitored by means of gene expression, which could aid in designing radiation treatment regimes for cancer patients leading to better restoration of spermatogenesis.

Male gonadal toxicity

Cancer treatment with chemotherapy or radiotherapy causes gonadal toxicity in male patients. The endpoint of most concern for future reproductive options is the induction of prolonged azoospermia, which may or may not be reversible. The immediate effects of therapy and its reversibility are most readily observed in post-pubertal patients, but the same antineoplastic regimens given to prepubertal males can induce permanent azoospermia. The probability of permanent azoospermia is related to the specific agents used and their doses. The most damaging are alkylating agents (particularly chlorambucil, procarbazine, cyclophosphamide, melphalan, and busulfan), cisplatin and radiation to the region of the testicles.

Donor Sertoli cells transplanted into irradiated rat testes stimulate partial recovery of endogenous spermatogenesis

Irradiation of rat testes leads to the failure to support differentiation of the surviving spermatogonia due to damage of the somatic environment. To determine the involvement of Sertoli cells in this somatic damage, we transplanted seminiferous tubule cells from normal immature GFP-transgenic rats into the testes of irradiated rats. The donor Sertoli cells colonized and developed in the host testes. In many seminiferous tubules, the donor Sertoli cells formed abnormal spherical structures in the lumen, but in some tubules they formed a normal-appearing epithelium, but with only isolated spermatogonia, on the basement membrane. When the donor cells were injected into the interstitial region of the testis, they formed tubule-like structures containing Sertoli cells and occasional isolated spermatogonia, both of donor origin. Surprisingly, in host tubules adjacent to these newly formed donor-cell tubules or adjacent to the endogenous tubules with abnormal donor Sertoli-cell structures, endogenous spermatogonia differentiated to the spermatocyte or even to spermatid stages. Around these newly donor cell-formed tubules and the host tubules with abnormal donor Sertoli-cell structures, many cells including macrophages, which perhaps represented chronic inflammation, accumulated in the interstitium. We conclude that the donor Sertoli cells that colonized the seminiferous tubules did not directly support recovery of spermatogenesis. Instead, the colonizing Sertoli cells acted indirectly on the interstitium to stimulate localized differentiation of endogenous spermatogonia.

Hormonal suppression for fertility preservation in males and females

Methods to restore fertility of men and women sterilized by medical treatments and environmental toxicant exposures are under investigation. Rendering spermatogenesis and ovarian follicular development kinetically quiescent by suppression of gonadotropins has been proposed to protect them from damage by cytotoxic therapy. Although the method fails to protect the fertility of male mice and monkeys, gonadotropin and testosterone suppression in rats before or after cytotoxic therapy do enhance the recovery of spermatogenesis. However, the mechanism involves not the induction of quiescence but rather the reversal, by suppression of testosterone, of a block in differentiation of surviving spermatogonia caused by damage to the somatic environment. In men, only one of eight clinical trials was successful in protecting or restoring spermatogenesis after cytotoxic therapy. In women, protection of primordial follicles in several species from damage by cytotoxic agents using GnRH analogs has been claimed; however, only two studies in mice appear convincing. The protection cannot involve the induction of quiescence in the already dormant primordial follicle but may involve direct effects of GnRH analogs or indirect effects of gonadotropin suppression on the whole ovary. Although numerous studies in female patients undergoing chemotherapy indicate that GnRH analogs might be protective of ovarian function, none of the studies showing protection were prospective randomized clinical trials and thus they are inconclusive. Considering interspecies differences and similarities in the gonadal sensitivity to cytotoxic agents and hormones, mechanistic studies are needed to identify the specific beneficial effects of hormonal suppression in select animal models that may be applicable to humans.

The radiation-induced block in spermatogonial differentiation is due to damage to the somatic environment, not the germ cells

Radiation and chemotherapeutic drugs cause permanent sterility in male rats, not by killing most of the spermatogonial stem cells, but by blocking their differentiation in a testosterone-dependent manner. However, it is not known whether radiation induces this block by altering the germ or the somatic cells. To address this question, we transplanted populations of rat testicular cells containing stem spermatogonia and expressing the green fluorescent protein (GFP) transgene into various hosts. Transplantation of the stem spermatogonia from irradiated adult rats into the testes of irradiated nude mice, which do not show the differentiation block of their own spermatogonia, permitted differentiation of the rat spermatogonia into spermatozoa. Conversely transplantation of spermatogonial stem cells from untreated prepubertal rats into irradiated rat testes showed that the donor spermatogonia were able to colonize along the basement membrane of the seminiferous tubules but could not differentiate. Finally, suppression of testosterone in the recipient irradiated rats allowed the differentiation of the transplanted spermatogonia. These results conclusively show that the defect caused by radiation in the rat testes that results in the block of spermatogonial differentiation is due to injury to the somatic compartment. We also observed colonization of tubules by transplanted Sertoli cells from immature rats. The present results suggest that transplantation of spermatogonia, harvested from prepubertal testes to adult testes that have been exposed to cytotoxic therapy might be limited by the somatic damage and may require hormonal treatments or transplantation of somatic elements to restore the ability of the tissue to support spermatogenesis.

Both testosterone and follicle-stimulating hormone independently inhibit spermatogonial differentiation in irradiated rats

Simultaneous suppression of both testosterone and FSH with GnRH antagonists (GnRH-ant) reverses the radiation-induced block in spermatogonial differentiation in F1 hybrids of Lewis and Brown-Norway rats. Although addition of exogenous testosterone restores the block, it also raises FSH, and hence it had not been possible to conclusively determine which hormone was inhibiting spermatogonial differentiation. In the present study, we establish the relative roles of testosterone and FSH in this inhibition using three different approaches. The first approach involved the treatment of irradiated rats, in which differentiation was stimulated by GnRH-ant plus flutamide, with FSH for 2 wk; the FSH reduced the percentage of tubules that were differentiated (TDI) by about 2-fold, indicating that FSH does have an inhibitory role. The second approach involved treatment of irradiated, hypophysectomized rats with exogenous testosterone for 10 wk; testosterone also reduced the TDI, demonstrating that testosterone had a definite inhibitory effect, independent of pituitary hormones. Furthermore, in this protocol we showed that TDI in the hypophysectomized testosterone-treated group, which had higher intratesticular testosterone levels but lacked FSH, was slightly higher than the TDI in a GnRH-antagonist-testosterone-treated group of irradiated rats, which had normal physiological levels of FSH; this result supports a role for endogenous FSH in suppressing spermatogonial differentiation in the latter group. The third approach involved injection of an active anti-FSH antibody for 10 d in untreated, GnRH-ant plus flutamide-treated, or GnRH-ant plus testosterone-treated irradiated rats. This was not sufficient to increase the TDI. However, flutamide given in a similar treatment schedule did increase the TDI in GnRH-ant plus testosterone-treated rats. We conclude that both testosterone and FSH individually inhibit spermatogonial differentiation after irradiation, but testosterone is a more highly potent inhibitor than is FSH.

Fertility, gonadal and sexual function in survivors of testicular cancer

Modern treatments cure most testicular cancer patients, so an important goal is to minimise toxicity. Fertility and sexual functioning are key issues for patients. We have evaluated these outcomes in a cross-sectional study of long-term survivors of testicular cancer. In total, 680 patients treated between 1982 and 1992 completed the EORTC Qly-C-30(qc30) questionnaire, the associated testicular cancer specific module and a general health and fertility questionnaire. Patients have been subdivided according to treatment received: orchidectomy either alone (surveillance, S n=169), with chemotherapy (C, n=272), radiotherapy (R, n=158), or both chemotherapy and radiotherapy (C/RT n=81). In the surveillance group, 6% of patients had an elevated LH, 41% an elevated FSH and 11% a low (<10 nmol l⁻¹) testosterone. Hormonal function deteriorated with additional treatment, but the effect in general was small. Low testosterone was more common in the C/RT group (37% P=0.006), FSH abnormalities were more common after chemotherapy (C 49%, C/RT 71% both P<0.005) and LH abnormalities after radiotherapy (11% P<0.01) and chemotherapy (10%, P<0.001). Baseline hormone data were available for 367 patients. After treatment, compared to baseline, patients receiving chemotherapy had significantly greater elevations of FSH (median rise of 6 (IQR 3–9.25) iu l⁻¹ compared to 3 (IQR 1–5) iu l⁻¹ for S; P<0.001) and a fall (compared to a rise in the surveillance group) in median testosterone levels (−2 (IQR −8.0 to −1.5) vs 1.0. (IQR −4.0–4.0) P<0.001). Patients with low testosterone (but not elevated FSH) had lower quality of life scores related to sexual functioning on the testicular cancer specific module and lower physical, social and role functioning on the EORTC Qly C-30. Patients with a low testosterone also had higher body mass index and blood pressure. Treatment was associated with reduction in sexual activity and patients receiving chemotherapy had more concerns about fathering children. In total, 207 (30%) patients reported attempting conception of whom 159 (77%) were successful and a further 10 patients were successful after infertility treatment with an overall success rate of 82%. There was a lower overall success rate after chemotherapy (C 71%; CRT 67% compared to S 85% (P=0.028)). Elevated FSH levels were associated with reduced fertility (normal FSH 91% vs elevated 68% P<0.001). In summary, gonadal dysfunction is common in patients with a history of testicular cancer even when managed by orchidectomy alone. Treatment with chemotherapy in particular can result in additional impairment. Gonadal dysfunction reduces quality of life and has an adverse effect on patient health. Most patients retain their fertility, but the risk of infertility is likely to be increased by chemotherapy. Screening for gonadal dysfunction should be considered in the follow-up of testicular cancer survivors.

Effects of medroxyprogesterone and estradiol on the recovery of spermatogenesis in irradiated rats

Suppression of intratesticular testosterone (ITT) levels is required for spermatogenic recovery in rats after irradiation, but maintenance of peripheral testosterone (T) levels is important for many male functions. Considering the preservation of peripheral T while suppressing ITT, we tested the effects of a combination of a progestin, medroxyprogesterone acetate (MPA), plus T on spermatogenic recovery after irradiation, and compared its effects to those of T alone or T combined with estradiol (E2). Rats were given testicular irradiation (6 Gy) and treated during wk 3-7 after irradiation with MPA + T, or the individual steroids with or without GnRH antagonist (GnRH-ant), or GnRH-ant alone, or T + E2. Whereas GnRH-ant alone stimulated differentiation in 55% of tubules 13 wk after irradiation compared with 0% in irradiated-only rats, the addition of MPA reduced the percentage of tubules showing differentiation to 18%. However, T or MPA alone or the combination of the two induced germ cell differentiation in only 2-4% of tubules. In contrast, E2 stimulated differentiation in 88% of tubules, and T combined with E2 still resulted in differentiation in 30% of tubules. Although both MPA and E2 suppressed ITT levels to approximately 2% of control (2 ng/g testis), MPA was a less effective stimulator of spermatogenic recovery than E2 or GnRH-ant alone. MPA's function as a weak androgen was likely responsible for inhibiting spermatogenic recovery, as was the case for all other tested androgens. Thus, for clinical protection or restoration of spermatogenesis after radiation or chemotherapy by suppressing T production, MPA, at least in the doses used in the present study, is suboptimal. The combination of an estrogen with T appears to be most effective for stimulating such recovery.

Suppression of testosterone stimulates recovery of spermatogenesis after cancer treatment

It is important to develop methods to prevent or reverse the infertility caused by chemotherapy or radiation therapy for cancer in men. Radiation and some chemotherapeutic agents kill spermatogonial stem cells, but we have shown that these cells survive in rats, although they are unable to differentiate. There is evidence that this phenomenon also occurs in men. The block to spermatogonial differentiation in rats is caused by some unknown change, either in the spermatogonia or the somatic elements of the testis, such that testosterone inhibits spermatogonial differentiation. In the rat, the spermatogenesis and fertility lost following treatment with radiation or some chemotherapeutic agents can be restored by suppressing testosterone with gonadotropin releasing hormone (GnRH) agonists or antagonists, either before or after the cytotoxic insult. The applicability of this procedure to humans is still unknown. Some anticancer regimens may kill all the stem cells, in which case the only option would be spermatogonial transplantation. However, in some cases stem cells survive and there is one report of stimulation of recovery of spermatogenesis with hormonal treatment. Clinical trials should focus on treating patients with hormones during or soon after anticancer treatment. The hormone regimen should involve suppression of testosterone production with minimum androgen supplementation used to improve the diminished libido.

Impact of cytotoxic treatment on long-term fertility in patients with germ-cell cancer

More than half of the patients with testicular germ-cell cancer show impaired spermatogenesis before undergoing cytotoxic treatment. The known pre-treatment infertility and the reversibility of the fertility problems observed in some after successful anti-cancer treatment have so far prevented an assessment of the true role of cytotoxic therapy in long-term fertility. The introduction of wait-and-see strategies (surveillance) for testicular cancer patients and recent prospective trials comparing patients with and without cytotoxic treatment have provided the means for estimating the extent to which treatment itself affects long-term fertility. Whether or not spermatogenesis is irreversibly impaired by chemotherapy is determined by the cumulative dose of cisplatin: at doses below 400 mg/m2, long-term effects on sperm production as well as on endocrine function are unlikely to occur. Higher doses should be expected to cause long-term losses of exocrine and endocrine gonadal function. In contrast, for adjuvant retroperitoneal radiotherapy in stage I seminoma patients, no data are available comparing long-term gonadal function with patients on surveillance. However, using modern radiation techniques, radiation doses to the para-aortic field (< 30 Gy) and testis shielding providing testis scatter radiation (< 30 cG), radiation-induced impairment of fertility is very unlikely.

Effect of vindesine sulfate on the radiation-induced alterations in mouse spermatogenesis: a flow cytometric evaluation

The effect of 0.05 mg/kg body weight of vindesine sulfate was studied on the radiation-induced changes in mouse spermatogenesis at 1, 2, 7, 14, 21, 28, 35 and 70 days post-irradiation. Vindesine administration before exposure to 0, 0.5, 1, 2 and 3 Gy gamma-irradiation resulted in an increase in the radiation-induced perturbations of mouse spermatogenesis at various post-exposure time periods studied. A significant reduction in testicular weight was observed in both DDW + irradiated and VDS + irradiated groups at various post-irradiation time periods, depending on the exposure dose. Vindesine pretreatment resulted in an enhanced killing of spermatogonial cells at day 2 post-exposure at all the exposure doses, except 3 Gy when compared to DDW + irradiated controls. Consequently, the tetraploid (4C) population declined significantly by day 14 post-irradiation followed by a severe depletion in round spermatids (1C) by day 21 post-irradiation. The dose-response relationship for 4C and 1C populations was linear-quadratic at days 14 and 21, respectively. A significant elevation was observed in HC population from days 1 to 21 depending on the exposure dose. The germ cell ratios, viz. 4C:2C, 4C:S-phase, 1C:2C and 1C:4C, showed a significant decline in the VDS + irradiated group when compared to the DDW + irradiated group at various time periods, depending on the exposure dose.

The value of the biopsy of the contralateral testis in patients with testicular germ cell cancer: the recent German experience

PURPOSE

Testicular intraepithelial neoplasia (TIN; so-called carcinoma in situ of the testis), the precursor of testicular germ cell neoplasms can be detected by testicular biopsy many years before the clinical manifestation of the tumour. This study looked at the prevalence of contralateral TIN in patients with testicular germ cell cancer. The purpose was to evaluate this new approach of early detection of testicular cancer and to evaluate the current management strategies.

PATIENTS, METHODS

1954 consecutive patients with unilateral testicular germ cell tumour underwent contralateral biopsy. All specimens were examined immunohistologically with staining for placental alkaline phosphatase. Patients with TIN were usually submitted to low-dose radiotherapy of the testis. A rebiopsy was performed after 3 months. Endocrinological evaluations were done before, during and after treatment.

RESULTS

TIN was observed in 4.9% (95% confidence intervals 3.95%-5.91%). Testicular atrophy constitutes a 4.3 fold increased risk of having contralateral TIN. 64% of the cases with TIN were found in clinically normal testes. Patients with TIN were significantly younger than those without (p < 0.017). No case with TIN was found in patients older than 50 years. Three patients developed a second testicular tumour during follow-up despite a negative biopsy. After radiotherapy, all of 23 patients had complete disappearance of TIN in the rebiopsy. After chemotherapy, 3 of 10 patients had persistent TIN histologically. After radiotherapy, 12 of 41 patients required testosterone replacement.

CONCLUSION

The prevalence of contralateral TIN accords well with the known prevalence of bilateral testicular tumours. Testicular atrophy is a strong indicator for the presence of TIN but about 60% of TIN-cases occur without atrophy. Local radiotherapy to the testis with 18-20 Gy is efficaceous in eradicating TIN, but it causes significant damage to almost one quarter of these patients. Chemotherapy is an unsafe treatment for TIN. This study shows the feasibility of early detection of testicular cancer in a high-risk population by means of searching for TIN. Although the management of the condition still needs refinement, the TIN-concept offers an avenue for the early detection of testicular cancer and early conservative management.

Hormonal stimulation of the recovery of spermatogenesis following chemo- or radiotherapy. Review article

Radiation and chemotherapeutic drugs produce prolonged depression of sperm counts in rodents and humans. Previously, three approaches have been developed in experimental animals that have had some success in preventing or reversing this toxicity. These approaches included pretreatment with hormones that suppress spermatogenesis, stimulation of stem cell number, and supplementation with testosterone. A different rationale for the ability of particular hormonal treatments to reverse prolonged azoospermia is presented in this review. In many cases prolonged azoospermia occurs even though the stem spermatogonia survive the toxic insult, but the differentiation of these spermatogonia to produce sperm fails. In the rat, the block appears to be at the differentiation of the A spermatogonia. Hormone treatments with testosterone or with GnRH agonists, which suppress intratesticular testosterone levels, relieve this block and result in the production of differentiating cells. When the hormone treatment is stopped the production of differentiating cells continues, mature sperm are produced, and fertility is restored. If a similar mechanism can be demonstrated to hold in humans, the fertility of men who have been rendered infertile by treatments for testicular and other cancers could be improved.

Fertility after chemotherapy for testicular germ cell cancer

OBJECTIVE

To investigate the impact of cytostatic chemotherapy on long-term fertility in patients with testicular germ cell cancer.

BACKGROUND

Many patients with testicular germ cell cancer show impaired spermatogenesis before undergoing cytotoxic chemotherapy. The known infertility before treatment and the reversibility of the fertility problems observed in some of them after successful anticancer treatment so far have prevented an assessment of the true impact of chemotherapy on long-term fertility. The introduction of a wait-and-see strategy (surveillance) for patients with testicular cancer and recent prospective trials comparing patients with and without cytotoxic chemotherapy now have provided the means for estimating the extent to which chemotherapy itself affects long-term fertility.

RESULT(S)

Whether spermatogenesis is impaired irreversibly by chemotherapy is determined by the cumulative dose of cisplatin. At cumulative doses > 400 mg/m2, irreversible impairment of gonadal function should be expected.

CONCLUSION(S)

At cumulative cisplatin doses < 400 mg (equivalent to 4 courses of state-of-the-art treatment), chemotherapy is unlikely to cause irreversible damage to fertility.

Endocrinological late effects after chemotherapy for testicular cancer

Type and extent of endocrinological alterations were studied in long-term disease-free survivors after cisplatin-based chemotherapy for testicular cancer. A total of 63 patients with a median age of 30 (19-53) years, and median follow-up of 42 (16-128) months were included. Elevated serum follicle-stimulating hormone (FSH) levels were found in 63% of patients, 24% showed pathologically elevated luteinising hormone (LH) levels with normal and 10% with subnormal testosterone levels. The degree of gonadotropin elevation was highly significantly correlated with the cumulative platinum (P) dose. Patients treated with platinum-vinblastine-bleomycin regimens showed higher gonadotropin levels than those treated with platinum-etoposide-bleomycin. The adrenal androgen dehydroepiandrosterone (DHEA), pathologically elevated in 68% of patients, was significantly correlated with the cumulative doses of chemotherapy (ctx) used and to the gonadotropin levels. Treatment variables, such as type and dose of cytotoxic agents used, as well as degree of gonadotropin elevation were further correlated with changes in oestron, testosterone and 17 alpha-OH-progesterone levels. Cholesterol levels were elevated in 32% of patients and significant interactions between the steroid hormone levels and cardiovascular risk factors could be shown.

Dose-dependent impairment of testicular function in patients treated with cisplatin-based chemotherapy for germ cell cancer

BACKGROUND

The enormous differences in semen quality following cisplatin-based combination chemotherapy reported in previous studies may be caused by differences in the cisplatin dosages.

PATIENTS AND METHODS

We examined thirty-three patients treated with conventional-dose PEB (cisplatin 20 mg/m2 x 5, q3w, etoposide 100 mg/m2 x 5 q3w and bleomycin 15 mg/m2 q1w) and 21 patients treated with high-dose PEB (cisplatin 40 mg/m2 x 5 q3w, etoposide 200 mg/m2 x 5 q3w and bleomycin 15 mg/m2 q1w).

RESULTS

The sperm density was significantly higher (median 5.83 mill/ml) in the conventionally-treated group than in the group of high-dose-treated patients (median 0.005 mill/ml) (p = 0.008). Azoospermia was present in 19% of the conventionally- and in 47% of the high-dose-treated patients. All patients treated with a cumulative cisplatin dose above 600 mg/m2 had severe oligospermia or azoospermia. Serum values of basal follicle-stimulating hormone (FSH) (median 27.2 iu/l vs. 15.2 iu/l) and stimulated FSH (median 57.7 iu/l vs. 28.4 iu/l) were significantly higher in the high-dose group than in the conventionally-treated group. No differences could be detected in basal or stimulated testosterone or in luteinizing hormone in serum.

CONCLUSION

In patients treated with PEB for testicular cancer, we found strong evidence that the impairment of spermatogenesis is dose-dependent.

Paternity in a patient with testicular seminoma and contralateral testicular intraepithelial neoplasia

A 32-year-old patient with unilateral beta hCG-positive seminoma and contralateral testicular intraepithelial neoplasia (TIN; so-called carcinoma-in-situ) with no metastases (clinical stage I) received one course of adjuvant carboplatin therapy. He refused further treatment of TIN in his remaining testis. His wife became pregnant by him 4 months later and delivered a healthy child at term. This case shows that patients with TIN in their remaining solitary testis are not necessarily infertile, and testes afflicted with TIN must also contain tubules that retain normal spermatogenic potential. Surveillance may be an treatment option for patients with TIN in their remaining testis in cases where there is a strong desire for paternity.

Recovery of fertility 14 years following radiotherapy and chemotherapy for testicular tumour

We report a patient who developed a left-sided malignant teratoma with ipsilateral para-aortic nodes at the age of 20 years. Following treatment with left orchidectomy, abdominal and pelvic radiotherapy and chemotherapy, he was found to be azoospermic. More than 14 years after treatment, he regained his fertility. Similar prolonged iatrogenic depression of spermatogenesis has been reported in younger lymphoma patients; however, in post-pubertal patients with testicular tumour this has not been frequently reported.

Follicle stimulating hormone levels as a predictor of recovery of spermatogenesis following cancer therapy

Infertility, both temporary and permanent, is a well-recognized complication of certain cancer treatments. The main objective of this study was to determine whether recovery of fertility in male patients, could be predicted by monitoring changes in serum follicle stimulating hormone (FSH) levels. Twenty male patients participated in the study. Sperm counts and serum FSH levels were measured before, during and after treatment. Azoospermia was universal in all 20 patients during the first year, with significantly raised FSH in almost all the patients. Reduction of FSH levels during the second year was frequently followed by recovery of spermatogenesis. Patients in whom the FSH did not fall during the second year were highly unlikely to regain fertility.