Fertility in men with testicular germ cell tumors

Fertility preservation in adult male patients with cancer: a systematic review and meta-analysis

STUDY QUESTION

Does sperm cryopreservation serve as a feasible and effective method for preserving fertility in adult male patients with cancer?

SUMMARY ANSWER

Sperm cryopreservation is an effective fertility preservation method and may benefit patients with cancer.

WHAT IS KNOWN ALREADY

Sperm cryopreservation is the only way to efficiently preserve male fertility. It is an important procedure in ART. Recently, due to remarkable advances in cancer treatment, an increasing number of studies have reported the outcomes of sperm cryopreservation in patients with cancer.

STUDY DESIGN SIZE DURATION

We conducted an extensive literature search for relevant studies published through to 31 December 2021, in the following databases: CENTRAL, CNKI, Cochrane Systematic Reviews, EMBASE, MEDLINE, PUBMED, and Web of Science. The search terms used were '(cryopreservation OR freeze OR freezing OR banking OR cryostorage OR storage) AND (sperm OR semen OR spermatozoon) AND (cancer OR tumor OR malignancy OR neoplasm)'.

PARTICIPANTS/MATERIALS SETTING METHODS

We included all studies that reported offering or attempting to cryopreserve sperm before or during cancer treatment in male patients considered at risk of treatment-related fertility impairment. We evaluated the eligibility of all data in each study. The major exclusion criteria were as follows: non-cancer patients; pediatric and adolescent cancer patients; not reporting the use of cryopreserved sperm; use of fresh semen for ART; not reporting the number of patients with cancer offered sperm cryopreservation or attempting to do so before or during treatment; using an experimental fertility preservation technique such as preservation of testicular tissue or spermatogonial stem cells; duplicate data; abstracts, case report, comments, reviews, or editorials; insufficient data reported. The quality of the included studies was assessed using the Newcastle-Ottawa scale and the Methodological Index for Non-Randomized Studies.

MAIN RESULTS AND THE ROLE OF CHANCE

This meta-analysis included 69 non-randomized studies, with 32 234 patients referred for sperm analysis and 23 178 patients cryopreserving at least one sperm sample. The pooled failed-to-cryopreserve rate was 10% (95% CI, 8-12%), and the sperm disposal and sperm use rates were 23% (95% CI, 16-30%) and 9% (95% CI, 8-10%), respectively. The pregnancy, miscarriage, and delivery rates were 28% (95% CI, 22-33%), 13% (95% CI, 10-17%), and 20% (95% CI, 15-25%), respectively. Subgroup analysis showed higher pregnancy and delivery rates, as well as a lower failed-to-cryopreserve rate, in recent studies compared to those released a decade ago. The studies from Asia reported higher sperm disposal and pregnancy rates than in other continents. Our analysis showed clinical pregnancy rates per cycle of 34% (27-41%), 24% (14-35%), and 9% (5-15%) and delivery rates per cycle of 23% (17-30%), 18% (11-26%), and 5% (1-9%) for ICSI, IVF, and IUI, respectively.

LIMITATIONS REASONS FOR CAUTION

As with all meta-analyses, some limitations should be considered. The first limitation of our study is that the data span 36 years. During this time, the World Health Organization has revised its sperm analysis standards, and other important changes have been made. There is also a limitation in that the outcome does not analyze the correlation between the type of cancer and sperm quality. Many of the earlier studies were limited by small sample sizes and a lack of control groups. Furthermore, almost all studies did not consider the severity of the disease, which could potentially have a substantial impact on the results. Consequently, further research should evaluate the effect of the type of cancer and, in particular, the severity of the condition on sperm quality in order to draw more precise conclusions. Similarly, it is inappropriate that most studies failed to differentiate between patients with different types of tumors and instead drew generalized conclusions that are presumed to apply to all patients with cancer. In the present analysis, we did not have in-depth information on patients' disease, and although extensive efforts were made to conduct a thorough systematic review and meta-analysis of the outcomes for patients with various types of tumors, the results must be acknowledged as being subject to bias. However, the use of average results obtained in each study, without the patient-level data, might also represent a source of bias.

WIDER IMPLICATIONS OF THE FINDINGS

Sperm cryopreservation is an effective fertility preservation method and may benefit patients with cancer. The observed utilization rate of frozen sperm at 9% may underestimate the actual usage, as the short follow-up period is inadequate for obtaining comprehensive data on the use of frozen sperm in young cancer survivors. ART plays an important role in fertility preservation and the achievement of pregnancy, with this meta-analysis showing that ICSI delivers better clinical outcomes than IVF or IUI in patients with cancer undergoing fertility preservation.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the National Natural Science Foundation of China (grant no. 82001634, 81960550), and the China Postdoctoral Science Foundation (2019M661521). There are no competing interests to declare.

REGISTRATION NUMBER

CRID 42022314460.

Identification of novel potential genes in testicular germ cell tumors: A transcriptome analysis

OBJECTIVE

Testicular germ cell tumors (TGCTs), containing pure seminoma and non-seminoma, occupy the most majority of testicular cancers in adolescents and young men, which has increased dramatically in recent decades. Therefore, it is important to find crucial genes for improving diagnosis and prognosis in TGCTs. However, the diagnostic and prognostic markers of TGCTs are limited.

METHODS

In this study, our main objective is to explore novel potential genes that can be used as diagnostic and prognostic biomarkers in TGCTs. Our study detected 732 differentially expressed genes (DEGs) using three microarray expression profiling datasets from Gene Expression Omnibus (GEO). Multiple analysis was performed to identify the roles of DEGs, including pathway and functional enrichment analysis, protein-protein interaction (PPI) network analysis, module analysis, and survival analysis.

RESULT

In total, 322 upregulated genes and 406 downregulated genes were identified as DEGs The functional and pathway enrichment analysis shows that DEGs were highly enriched in multiple biological attributes such as T cell activation, reproduction in multicellular organism, sperm flagellum, antigen processing and presentation Then, seven potential crucial genes were identified via PPI network analysis, module analysis, and survival analysis. Furthermore, 7 potential crucial genes had shown to play a key role in regulating immune cell infiltration level in patients with TGCTs.

CONCLUSION

We identified seven potential crucial genes (LAPTM5, NCF2, PECAM1, CD14, COL4A2, ANPEP and RGS1), which may be molecular markers in improving the way of diagnosis and prognosis in TGCTs.

Genomic instability and the link to infertility: A focus on microsatellites and genomic instability syndromes

Infertility is associated to multiple types of different genomic instabilities and is a genetic feature of genomic instability syndromes. While the mismatch repair machinery contributes to the maintenance of genome integrity, surprisingly its potential role in infertility is overlooked. Defects in mismatch repair mechanisms contribute to microsatellite instability and genomic instability syndromes, due to the inability to repair newly replicated DNA. This article reviews the literature to date to elucidate the contribution of microsatellite instability to genomic instability syndromes and infertility. The key findings presented reveal microsatellite instability is poorly researched in genomic instability syndromes and infertility.

Patient Reported Outcomes, Paternity, Relationship, and Fertility in Testicular Cancer Survivors: Results from a Prospective Observational Single Institution Trial

PURPOSE

Testicular cancer (TC) is the most common solid tumor in young adults. 95% of patients are cured, but they may experience late adverse effects (anxiety, fear of recurrence, and sexual dysfunction) with an impact on daily life. We attempted to assess Patient Reported Outcomes (PROMs), long-term sexual disorders, and difficulties in achieving fatherhood in a cohort of TC survivors, as well as their possible correlation with previous cancer treatments.

METHODS

Different questionnaires, such as the Impact of Cancer (IOC) and the Body Image Scale (BIS), were used to investigate the distinct areas of the PROMs. International Index of Erectile Function (IIEF15) and the Premature Ejaculation Diagnostic Tool (PEDT) focused on sexuality and fertility. Patients were prospectively recruited between February 2020 and February 2022.

RESULTS

144 participants completed all the questionnaires. Results showed a good QoL, a moderate fear of TC recurrence, a good satisfaction with their personal body image, low incidence of premature ejaculation and erectile dysfunction. 19.5% of patients who had a testicular implant reported general dissatisfaction. Only 18% of patients had unsuccessfully attempted fatherhood, while the majority had not yet tried, and 23.4% succeeded. A low percentage of patients used procedures assisted reproduction and adoption.

CONCLUSION

This trial supports the use of various questionnaires as a multifactorial tool capable of investigating all the aspects of long-term cancer survivorship. The assessment of medical and psychosocial sequelae is an essential part of patient care and is important for the development of a comprehensive care plan for TC survivors.

Fertility and reproductive technology use in testicular cancer survivors in Japan: A multi-institutional, cross-sectional study

OBJECTIVE

To evaluate fertility and use of reproductive technology of testicular cancer survivors in a multi-institutional, cross-sectional study.

METHODS

This study recruited testicular cancer survivors who were followed after treatment for testicular cancer at eight high-volume institutions between 2018 and 2019. The participants completed the questionnaires on marital status, fertility and use of reproductive technology.

RESULTS

A total of 567 testicular cancer survivors, with a median age of 43 years, responded to the questionnaire. Chemotherapy was given to 398 survivors, including three cycles of cisplatin-based chemotherapy in 106 patients and four cycles in 147 patients. Among 153 survivors who attempted sperm cryopreservation, 133 (87%) could preserve sperm. Of the 28 survivors whose cryopreserved sperm was used, 17 (61%) fathered children. Of the 72 survivors who fathered children without the use of cryopreserved sperm, 59 (82%) fathered naturally. Whereas 33 (20%) of 169 survivors treated without chemotherapy fathered children without using cryopreserved sperm, 39 (10%) of 398 treated with chemotherapy fathered children (P < 0.05). Furthermore, the paternity rate was 12% and 5% in testicular cancer survivors with three and four cycles of cisplatin-based chemotherapy, respectively (P < 0.05). However, of 121 survivors who wanted to have children, 14 (12%) received counseling about infertility treatment.

CONCLUSIONS

Testicular cancer survivors preserving their sperm have a higher paternity rate after chemotherapy, especially after four cycles, than those not using cryopreserved sperm. Physicians who give chemotherapy for testicular cancer need to take particular care not only with respect to recurrence of testicular cancer, but also to post-treatment fertility.

Late adverse effects and quality of life in survivors of testicular germ cell tumour

Currently, ~95% of patients with testicular germ cell tumour (TGCT) are cured, resulting in an increasing number of TGCT survivors. Although cured, these men face potential late adverse effects and reduced quality of life. Survivors face a twofold increased risk of second malignant neoplasms after chemotherapy and radiotherapy, with evidence of dose-dependent associations. For survivors managed with surveillance or treated with radiotherapy, the risk of cardiovascular disease (CVD) is comparable to the risk in the general population, whereas treatment with chemotherapy increases the risk of life-threatening CVD, especially during treatment and after 10 years of follow-up. Other adverse effects are organ-related toxicities such as neuropathy and ototoxicity. Pulmonary and renal impairment in patients with TGCT treated with chemotherapy is limited. Survivors of TGCT might experience psychosocial distress including anxiety disorders, fear of cancer recurrence and TGCT-specific issues, such as sexual dysfunction. Late adverse effects can be avoided in most patients with stage I disease if followed on a surveillance programme. However, patients with disseminated disease can experience toxicities associated with radiotherapy and chemotherapy, and/or adverse effects related to surgery for residual disease. The severity of adverse effects increases with dose of both chemotherapy and radiotherapy. This Review discusses the most recent data concerning the late adverse effects of today's standard treatments for TGCT.

[Onco-TESE and testicular cancer]

INTRODUCTION

Fertility preservation is essential before cancer treatment. When ejaculated sperm preservation is not possible, testicular tissue can be surgically collected by Onco-TESE technic (Oncological Testicular Sperm Extraction) to isolate sperm. We report on our experience with Onco-TESE in testicular cancer patients at the Rouen University Hospital.

MATERIAL AND METHOD

Retrospective study including all pubescent men, treated for testicular cancer, uni- or bilateral, before any carcinological therapy, who have undergone Onco-TESE at the Rouen University Hospital. Fragment weight, detection of sperm or its precursors were analysed. A histological interpretation of the testicular tumor was carried out. For each positive sample, straws were kept at the French Sperm Bank.

RESULTS

Twenty-four patients had an Onco-TESE: 58.34% severe sperm alteration (SSA) and 41.36% sperm collection failure (SCF), between 1996 and 2019. The mean age was 26.6 (±5.29) years. The mean procedure and length of stay were 71minutes (±30.7) and 3.75 days (±2.83), respectively. The rate of positive testicular biopsies (TB) was 58.33% overall and 66,67% in the case of TB on tumour testis. One patient had a Clavian-Dindo III complication. The mean number of straws preserved per patient was 14.28 (±15.34) for 7.14% use.

CONCLUSION

Our results seem to confirm that Onco-TESE is an effective solution for preserving fertility in men with testicular cancer in cases of SSA or SCF.

LEVEL OF EVIDENCE

III.

Testicular Cancer Survivorship

Testicular cancer (TC) is the most common cancer among men aged 18 to 39 years. It is highly curable, with a 10-year relative survival approaching 95% due to effective cisplatin-based chemotherapy. Given the increasing incidence of TC and improved survival, TC survivors (TCS) now account for approximately 4% of all US male cancer survivors. They have also become a valuable cohort for adult-onset cancer survivorship research, given their prolonged survival. Commensurately, long-term treatment-related complications have emerged as important survivorship issues. These late effects include life-threatening conditions, such as second malignant neoplasms and cardiovascular disease. Moreover, TCS can also experience hearing loss, tinnitus, neurotoxicity, nephrotoxicity, pulmonary toxicity, hypogonadism, infertility, anxiety, depression, cognitive impairment, and chronic cancer-related fatigue. Characterization of the number and severity of long-term adverse health outcomes among TCS remains critical to develop risk-stratified, evidence-based follow-up guidelines and to inform the development of preventive measures and interventions. In addition, an improved understanding of the long-term effects of TC treatment on mortality due to noncancer causes and second malignant neoplasms remains paramount. Future research should focus on the continued development of large, well-characterized clinical cohorts of TCS for lifelong follow-up. These systematic, comprehensive approaches can provide the needed infrastructure for further investigation of long-term latency patterns of various medical and psychosocial morbidities and for more in-depth studies investigating associated etiopathogenetic pathways. Studies examining premature physiologic aging may also serve as new frontiers in TC survivorship research.

Distinct Proteomic Profile of Spermatozoa from Men with Seminomatous and Non-Seminomatous Testicular Germ Cell Tumors

Testicular germ cell tumors (TGCTs) are predominant in young males (15–44 years). Seminomatous and non-seminomatous TGCTs account for about 98% of all TGCTs cases. In this study, we aimed to compare the sperm proteome of patients with seminomatous and non-seminomatous TGCTs to identify possible protein biomarkers that could help distinguish between them in a non-invasive manner. We analyzed semen samples from patients with seminomatous or non-seminomatous TGCTs (n = 15/group) that were cryopreserved before the start of cancer treatment. Quantitative proteomic analysis was conducted on pooled samples (n = 3/group) and a total of 258 differentially expressed proteins (DEPs) were identified. The overexpression of acrosin precursor (ACR) and chaperonin containing TCP1 subunit 6B (CCT6B) as well as the underexpression of S100 calcium-binding protein A9 (S100A9) in the spermatozoa of patients with non-seminomatous TGCTs were validated by western blotting conducted on individual samples (n = 6 for seminomatous group and n = 6 for non-seminomatous group). Our overall results suggest an association between the higher and faster invasiveness of non-seminomatous TGCTs and the altered protein expressions, providing important information for future studies.

New Insights on the Mechanisms Affecting Fertility in Men with Non-Seminoma Testicular Cancer before Cancer Therapy

Purpose

Patients with non-seminoma testicular cancer (NSTC) cancer can be subfertile or infertile, and present reduced sperm quality, but the underlying mechanisms are unknown. The aim of this study was to compare the sperm proteome of patients with NSTC, who cryopreserved their sperm before starting cancer treatment, with that from healthy fertile men.

Materials and Methods

Semen volume, sperm motility and sperm concentration were evaluated before the cryopreservation of samples from patients with NSTC (n=15) and the control group (n=15). Sperm proteomic analysis was performed by liquid chromatography-tandem mass spectrometry and the differentially expressed proteins (DEPs) between the two groups were identified using bioinformatic tools.

Results

A total of 189 DEPs was identified in the dataset, from which five DEPs related to sperm function and fertilization were selected for validation by Western blot. We were able to validate the underexpression of the mitochondrial complex subunits NADH:Ubiquinone Oxidoreductase Core Subunit S1 (NDUFS1) and ubiquinol-cytochrome C reductase core protein 2 (UQCRC2), as well as the underexpression of the testis-specific sodium/potassium-transporting ATPase subunit alpha-4 (ATP1A4) in the NSTC group.

Conclusions

Our results indicate that sperm mitochondrial dysfunction may explain the observed decrease in sperm concentration, total sperm count and total motile count in NSTC patients. The identified DEPs may serve as potential biomarkers for the pathophysiology of subfertility/infertility in patients with NSTC. Our study also associates the reduced fertilizing ability of NSTC patients with the dysregulation of important sperm molecular mechanisms.

Toxicities Associated with Cisplatin-Based Chemotherapy and Radiotherapy in Long-Term Testicular Cancer Survivors

Testicular cancer has become the paradigm of adult-onset cancer survivorship, due to the young age at diagnosis and 10-year relative survival of 95%. This clinical review presents the current status of various treatment-related complications experienced by long-term testicular cancer survivors (TCS) free of disease for 5 or more years after primary treatment. Cardiovascular disease and second malignant neoplasms represent the most common potentially life-threatening late effects. Other long-term adverse outcomes include neuro- and ototoxicity, pulmonary complications, nephrotoxicity, hypogonadism, infertility, and avascular necrosis. Future research efforts should focus on delineation of the genetic underpinning of these long-term toxicities to understand their biologic basis and etiopathogenetic pathways, with the goal of developing targeted prevention and intervention strategies to optimize risk-based care and minimize chronic morbidities. In the interim, health care providers should advise TCS to adhere to national guidelines for the management of cardiovascular disease risk factors, as well as to adopt behaviors consistent with a healthy lifestyle, including smoking cessation, a balanced diet, and a moderate to vigorous intensity exercise program. TCS should also follow national guidelines for cancer screening as currently applied to the general population.

Fatherhood and Sperm DNA Damage in Testicular Cancer Patients

Testicular cancer (TC) is one of the most treatable of all malignancies and the management of the quality of life of these patients is increasingly important, especially with regard to their sexuality and fertility. Survivors must overcome anxiety and fears about reduced fertility and possible pregnancy-related risks as well as health effects in offspring. There is thus a growing awareness of the need for reproductive counseling of cancer survivors. Studies found a high level of sperm DNA damage in TC patients in comparison with healthy, fertile controls, but no significant difference between these patients and infertile patients. Sperm DNA alterations due to cancer treatment persist from 2 to 5 years after the end of the treatment and may be influenced by both the type of therapy and the stage of the disease. Population studies reported a slightly reduced overall fertility of TC survivors and a more frequent use of ART than the general population, with a success rate of around 50%. Paternity after a diagnosis of cancer is an important issue and reproductive potential is becoming a major quality of life factor. Sperm chromatin instability associated with genome instability is the most important reproductive side effect related to the malignancy or its treatment. Studies investigating the magnitude of this damage could have a considerable translational importance in the management of cancer patients, as they could identify the time needed for the germ cell line to repair nuclear damage and thus produce gametes with a reduced risk for the offspring.

Physical long-term side-effects in young adult cancer survivors: germ cell tumors model

PURPOSE OF REVIEW

After the important advances in the treatment of germ cell tumors (GCTs) leading to high cure rates, physical long-term side-effects represent an important cause of death in these young adult survivors. Highlighting these physical long-term side-effects, their monitoring and their prevention modalities is necessary for a better management of these cancer survivors.

RECENT FINDINGS

Impaired fertility, increased risk of developing a second cancer, cardiac, pulmonary, renal and neural toxicity, hearing and vision impairment are the major physical side-effects in young adult cancer survivors. Long-term cardiac toxicity, next to second malignancies, represents life-threatening conditions in testicular cancer survivors. The long-term nephrotoxity in testicular GCTs survivors is most frequently associated to the treatment either in those treated with cisplatin-based chemotherapy, mainly Bleomycine, Etoposide, Cisplatin, or those receiving infradiaphragmatic radiation therapy, whereas pulmonary toxicity is mainly attributed to bleomycin related toxicities.

SUMMARY

There are no clear and comprehensive data concerning the monitoring and prevention of long-term side-effects in testicular cancer survivors. Physical activity and interventions in modifiable cardiovascular risk factors and lifestyles may reduce the incidence of long-term side-effects in these cancer survivors.

Fertility preservation of patients with testicular cancer

Background

Testicular cancer (TC) is one of the most common malignancies in young men of reproductive age. Although TC is a curable malignancy with a high survival rate, its treatment requires various cytotoxic modalities and negatively impacts spermatogenesis; therefore, the fertility preservation of patients with TC has been studied.

Methods

In order to give an overview of fertility preservation in patients with TC, the literature was reviewed. Original and review articles were identified and examined on the basis of PubMed database searches.

Results

Chemotherapy and radiotherapy damage spermatogenesis and retroperitoneal lymph node dissection negatively impacts ejaculatory function. Testicular sperm extraction facilitates successful sperm retrieval in patients with TC with postchemotherapy azoospermia. Although preserved sperm is used with a very low frequency (8%), the conception rates in those who have used sperm are not inferior.

Conclusion

The number of studies is limited, and because numerous treatment factors affect fertility, outstanding questions remain about preserving the fertility of patients with TC. Further studies are necessary in order to determine the best means of preventing and treating infertility in patients with TC.

Synchronous bilateral testis cancer: clinical and oncological management

Synchronous bilateral testis cancer (SBTC) is a rare event. It represents only 0.5–1% of all new cases of testicular cancer. Patients with this disease require careful management for psychological, oncological, and medical problems.

We performed a PubMed search for all series that reported SBTC. We considered only articles in English, reporting on more than three cases. We also performed an analysis of the reported evidence regarding testosterone replacement and surgical treatment.

We found 10 studies satisfying inclusion criteria for a total of 73 patients. The majority are bilateral seminoma, which present with a low stage at diagnosis, and mixed histology tumours, both with a good overall survival. On the other hand, cases with bilateral non-seminoma histology are associated with poor prognosis and high stage at presentation.

Testis-sparing surgery should be an eligible choice in selected cases, to preserve fertility and avoid testosterone deficiency. Multiple biopsies are recommended in these patients, and in the case of intratubular germ cell neoplasia (ITGCN) presence, scrotal radiotherapy is mandatory. Subcutaneous testosterone pellets guarantee higher patient acceptance and physiological testosterone levels. Lifelong follow-up and psychological support, with special care for infertility and erectile dysfunction, must be considered in this cohort of patients.

Sperm DNA Fragmentation Index and Hyaluronan Binding Ability in Men from Infertile Couples and Men with Testicular Germ Cell Tumor

Objective. To investigate sperm DNA fragmentation and sperm functional maturity in men from infertile couples (IC) and men with testicular germ cell tumor (TGCT). Materials and Methods. Semen samples were collected from 312 IC men and 23 men with TGCT before unilateral orchiectomy and oncological treatment. The sperm chromatin dispersion test was performed to determine DNA fragmentation index (DFI) and the ability of sperm to bind with hyaluronan (HA) was assessed. Results. In comparison with the IC men, the men with TGCT had a higher percentage of sperm with fragmented DNA (median 28% versus 21%; p < 0.01) and a lower percentage of HA-bound sperm (24% versus 66%; p < 0.001). Normal results of both analyses were observed in 24% of IC men and 4% of men with TGCT. Negative Spearman's correlations were found between DFI and the percentage of HA-bound sperm in the whole group and in IC subjects and those with TGCT analyzed separately. Conclusions. Approximately 76% of IC men and 96% with TGCT awaiting orchiectomy demonstrated DNA fragmentation and/or sperm immaturity. We therefore recommend sperm banking after unilateral orchiectomy, but before irradiation and chemotherapy; the use of such a deposit appears to be a better strategy to obtain functionally efficient sperms.

Testicular cancer

Testicular cancer is a rare condition, accounting for approximately 1-1.5% of all cancers in men. It is the most common cancer affecting men in their 20s and 30s. Little is known about the exact cause of this disease, although numerous risk factors have been recognised.

Treatment of testicular cancer has been extremely successful, with impressive cure rates reported. This is due to the excellent tumour response to chemotherapy and radiotherapy, and also to the diagnosis and follow-up regimes.

Role of melatonin in mitigating chemotherapy-induced testicular dysfunction in Wistar rats

Testicular cancer is the most common cancer affecting men of reproductive age, and its incidence is increasing steadily. A regimen of cisplatin (P), vinblastin (V) and bleomycin (B) (PVB) is the standard chemotherapy for testicular cancer. Though PVB-based chemotherapy has been widely used against germ cell tumors, it is associated with induction of oxidative toxicity and a transient or permanent loss of fertility. However, the mechanism of action of PVB on the testis is not thoroughly elucidated. Using a rat model, we investigated the persistence of the effects of PVB on steroidogenesis, spermatogenesis and testicular oxidative status and architecture. Further, we have also studied whether administration of melatonin has any protective effect on testicular physiology in the PVB-treated rats, since melatonin exerts influence on the antioxidant defense system. The body weight of the PVB-treated rats did not show significant change as compared with the control group. Significant decrease in the weight of the testis was observed with a reduction in volume in the PVB-treated rats. Administration of PVB caused a reduction in the testicular steroidogenesis and spermatogenesis. The circulatory levels of testosterone were also significantly reduced with an elevation of FSH and LH in the PVB-treated rats. Testicular architecture was severely affected with a reduction in seminiferous tubule diameter and epithelial height. The activities of superoxide dismutase and catalase were decreased while the levels of lipid peroxidation increased significantly in the testis of the PVB-treated rats indicating depletion of antioxidant defence system and elevation of oxidative stress. Co-administration of melatonin mitigated these changes in the PVB-treated rats.

The Association Between Testis Cancer and Semen Abnormalities Before Orchiectomy: A Systematic Review

Purpose: Testicular germ cell tumors (TGCT) are the most common solid organ malignancy in young men. It is a largely curable disease, so the extent to which it affects quality of life-including male fertility-is important. Abnormal semen analysis is highly predictive of male infertility. We conducted a systematic review of published studies that reported pre-orchiectomy semen parameters (as a surrogate for fertility) in TGCT patients to evaluate the association between TGCT and semen abnormalities before orchiectomy. Methods: We conducted a systematic review of peer-reviewed publications reporting semen parameters before orchiectomy in adult patients diagnosed with TGCT. Further, we assessed the association between TGCT and semen abnormalities that may lead to infertility. Results: We applied MeSH search terms to four online databases (PubMed, Cochrane Reviews, Web of Science, and Ovid), resulting in 701 potentially relevant citations. After conducting a three-stage screening process, six articles were included in the systematic review. For each study, the participants' data and the study's quality and risk of bias were assessed and described. All studies showed semen abnormalities-including count, motility, and morphology-in men with TGCT prior to orchiectomy. Conclusions: TGCT is associated with semen abnormalities before orchiectomy. This review shows an increase in abnormal semen parameters among men with TGCT even outside the treatment effects of orchiectomy, radiation, or chemotherapy. To improve long-term quality of life, these findings should be considered when counseling patients on future fertility and sperm banking during discussions about treatment and prognosis for TGCT.

Fertility outcome of patients with testicular tumor: before and after treatment

Testicular cancer (TC) is the most curable type of cancer, with a survival rate of more than 95%. Oncologists are faced with the challenge that gonadotoxic cancer treatments can compromise future fertility, either temporarily or permanently. Our aim was to investigate the long-term effects of TC treatments on male fertility and on the offspring of patients who had received these treatments. Between January 1996 and December 2010, 125 eligible patients, ranging from 18 to 54 years (median age 36.3 ± 15.7), with unilateral TC underwent surgery, chemotherapy or radiotherapy at our center. Some of these patients had their semen samples cryopreserved in the Shanghai Human Sperm Bank. The clinical data were evaluated, and questionnaire and telephone follow-up surveys were given to all patients. The data were analyzed to determine the patients’ fertility status pre- and posttreatment. Of the 125 eligible patients, 93.6% (117/125) were accessible and were evaluated. Among 81 men who were married before diagnosis, 21 had conceived successfully before diagnosis and six reported azoospermia. Posttreatment conception was attempted by 73 men; of these, 16 conceived naturally and 19 conceived by artificial reproductive techniques, resulting in 37 healthy babies with no congenital malformations. Of the patients who had not conceived before treatment, 21.9% (21/96) banked their sperm and 23.8% of these patients (5/21) subsequently used the banked sperm. Retroperitoneal lymph node dissection, chemotherapy and radiotherapy were the most highly correlated with lack of conception post-TC treatment. Sperm banking should be recommended to TC patients with the desire for biological conception. There is no evidence to suggest that TC treatments are associated with birth defects or childhood malignancies.

Sperm counts and endocrinological markers of spermatogenesis in long-term survivors of testicular cancer

Background:

The objective of this study was to assess markers of spermatogenesis in long-term survivors of testicular cancer (TC) according to treatment, and to explore correlations between the markers and associations with achieved paternity following TC treatment.

Methods:

In 1191 TC survivors diagnosed between 1980 and 1994, serum-follicle stimulating hormone (s-FSH; n=1191), s-inhibin B (n=441), and sperm counts (millions per ml; n=342) were analysed in a national follow-up study in 1998–2002. Paternity was assessed by a questionnaire.

Results:

At median 11 years follow-up, 44% had oligo- (<15 millions per ml; 29%) or azoospermia (15%). Sperm counts and s-inhibin B were significantly lower and s-FSH was higher after chemotherapy, but not after radiotherapy (RT), when compared with surgery only. All measures were significantly more abnormal following high doses of chemotherapy (cisplatin (Cis)>850 mg, absolute cumulative dose) compared with lower doses (Cis ⩽850 mg). Sperm counts were moderately correlated with s-FSH (−0.500), s-inhibin B (0.455), and s-inhibin B : FSH ratio (−0.524; all P<0.001). All markers differed significantly between those who had achieved post-treatment fatherhood and those with unsuccessful attempts.

Conclusion:

The RT had no long-term effects on the assessed markers of spermatogenesis, whereas chemotherapy had. At present, the routine evaluation of s-inhibin B adds little in the initial fertility evaluation of TC survivors.

Long-term and late effects of germ cell testicular cancer treatment and implications for follow-up

Germ cell testicular cancer (TC) represents a malignancy with high cure rates. Since the introduction of cisplatin-based chemotherapy in the late 1970s, the 5-year survival rate has increased considerably, and it is currently above 95%. Because TC is usually diagnosed before the age of 40 years, these men can expect to live for another 40 to 50 years after being successfully treated. This success, however, is hampered by an increased risk of long-term and late effects of treatment. Secondary malignant neoplasms and cardiovascular disease represent the most common potentially life-threatening late effects, typically occurring more than 10 years after treatment. Other long-term effects include pulmonary toxicity, nephrotoxicity, neurotoxicity, decreased fertility, hypogonadism, and psychosocial problems. The incidence and time to onset of these various adverse effects vary according to treatment type and intensity. There is still little knowledge about underlying mechanisms and genetic susceptibility of the various adverse effects. Apart from treatment burden, it is not yet possible to identify patients who are at high risk for certain late effects after TC treatment. In this clinical review, we present the current status regarding different somatic and psychosocial long-term late effects after treatment for TC, based on Medline searches and our own research. Moreover, we postulate recommendations for general medical evaluations that should begin after treatment is completed and continue during follow-up.

Testicular cancer survivorship

Because of a rising incidence of, and declining mortality from, testicular cancer, there are an increasing number of survivors of testicular cancer. Given their young age at diagnosis, the survivors have many years of life ahead of them during which they may experience adverse consequences from cancer and its treatment. Over the past few decades and particularly in this century, research into the short- and long-term effects of treatments of testicular cancer has grown rapidly, and now there exist a much greater body of data to help us counsel patients about the risks and side effects of these treatments.

Sequelae of treatment in long-term survivors of testis cancer

CONTEXT

Testicular cancer patients are often diagnosed at a young age, and because of the advances in the treatment of this disease, the vast majority have a normal life expectancy after therapy. Thus, recognition of the long-term sequelae of treatment (ie, surgery, radiation therapy, and chemotherapy) is particularly important in these patients.

OBJECTIVE

To review the adverse effects and the risk of secondary malignancy in long-term survivors of testicular cancer.

EVIDENCE ACQUISITION

We conducted a Medline search to identify original articles and reviews on the long-term effects of testicular cancer treatment. Although the search included articles from January 1948 to February 2011, the majority of the included articles were published in the last two decades.

EVIDENCE SYNTHESIS

All studies examining the long-term sequelae of treatment in testicular cancer are retrospective in nature, with most classified as cohort, case-control, and/or epidemiologic studies. Given that no standardized method of reporting long-term complications exists, evidence synthesis is limited.

CONCLUSIONS

Recent evidence suggests an increased risk of cardiovascular disease, neurotoxicity, and mild reductions in renal function in survivors of testicular cancer. Treatment of testicular malignancy can also negatively affect gonadal function and fertility and has been shown to result in an increased risk of solid malignancy and leukemia.

Romantic and sexual relationships, body image, and fertility in adolescent and young adult testicular cancer survivors: a review of the literature

This review presents a summary of existing knowledge regarding the effect of testicular cancer along four broad domains, including romantic and sexual relationships, body image, and fertility. A total of 37 studies were reviewed. Of note, most research consists of older adult testicular cancer survivors, with very little research attention afforded to adolescent and young adult survivorship. Relationship status (i.e., partnered versus unpartnered) appears to play an important role as it relates to adjustment outcomes in testicular cancer survivors. In addition, sexual function (and thereby fertility) and body image are also frequently compromised. Implications regarding a lack of developmentally focused research on adolescent and young adult testicular cancer survivorship are discussed, along with recommendations for new research.

Fertility among testicular cancer survivors: a case-control study in the U.S

INTRODUCTION

Testicular germ cell tumors (TGCT) disproportionately affect men between the ages of 15 and 49 years, when reproduction is typical. Although TGCT treatment directly affects gonadal tissues, it remains unclear whether there are long-term effects on fertility.

METHODS

To examine post-TGCT treatment fertility, study participants in a previously conducted case-control study were contacted. The men were initially enrolled in the US Servicemen's Testicular Tumor Environmental and Endocrine Determinants (STEED) study between 2002 and 2005. A total of 246 TGCT cases and 236 controls participated in the current study and completed a self-administered questionnaire in 2008-2009.

RESULTS

TGCT cases were significantly more likely than controls to experience fertility distress (OR 5.23; 95% CI 1.99-13.76) and difficulty in fathering children (OR 6.41; 2.72-15.13). Cases were also more likely to be tested for infertility (OR 3.65; 95% CI 1.55-8.59). Cases, however, did not differ from controls in actually fathering children (OR 1.37; 95% CI 0.88-2.15). These findings were predominantly observed among nonseminoma cases and cases treated with surgery only or surgery-plus-chemotherapy.

DISCUSSION

While expressing greater fertility distress, higher likelihood of fertility testing, and difficulty fathering children, these data suggest that TGCT survivors are no less likely to father children than are other men. It is possible that treatment for TGCT does not permanently affect fertility or, alternatively, that TGCT survivors attempt to father children with greater persistence or at younger ages than do other men.

Late complications of chemotherapy in testicular cancer

Cisplatin-based treatment has significantly increased survival in testicular cancer patients. Therefore, there has been enough interest for the late toxic effects of chemotherapy which affect the quality of life of the cancer survivors. These toxic effects may either persist or present long after the end of chemotherapy and involve the impairment of renal function, neurotoxicity, pulmonary toxicity and vascular disease. Also, a major issue experienced by a large number of patients is infertility, which has been improved due to modified surgical techniques, reduced treatment intensity, the use of sperm cryopreservation and methods of assisted reproduction. Physicians should also be aware of the risk of secondary malignancy development. Therefore, close follow-up of the testicular cancer survivors as well as, focus on minimizing treatment complications through improvement of treatment strategies are warranted.

Impact of the chemotherapy cocktail used to treat testicular cancer on the gene expression profile of germ cells from male Brown-Norway rats

Advances in treatment for testicular cancer that include the coadministration of bleomycin, etoposide, and cisplatin (BEP) have brought the cure rate to higher than 90%%. The goal of this study was to elucidate the impact of BEP treatment on gene expression in male germ cells. Brown-Norway rats were treated for 9 wk with vehicle (0x) or BEP at doses equivalent to 0.3x and 0.6x the human dose. At the end of treatment, spermatogenesis was affected, showing altered histology and a decreased sperm count; spermatozoa had a higher number of DNA breaks. After 9 wk of treatment, round spermatids were isolated, and RNA was extracted and probed on Rat230-2.0 Affymetrix arrays. Of the 31 099 probe sets present on the array, 59%% were expressed in control round spermatids. BEP treatment significantly altered the expression of 221 probe sets, with at least a 1.5-fold change compared with controls; 80% were upregulated. We observed a dose-dependent increase in the expression of oxidative stress response genes and no change in the expression of genes involved in DNA repair. BEP upregulated genes were implicated in pathways related to Jun and Junb protooncogenes. Increased mRNA levels of Jun and Junb were confirmed by quantitative RT-PCR; furthermore, JUN protein was increased in elongating spermatids. Thus, BEP exposure triggers an oxidative stress response in round spermatids and induces many pathways that may lead to the survival of damaged cells and production of abnormal sperm.

Sperm nuclear apoptotic DNA fragmentation in men with testicular cancer

OBJECTIVE

To verify whether sperm from patients with a seminoma and patients with a non-seminoma present with an increased rate of apoptotic DNA fragmentation, when compared with men without testicular cancer and who had fathered a child in the 2 years preceding the study.

DESIGN

Controlled prospective study.

SETTING

Patients referred to a sperm bank in an academic research environment.

PATIENT(S)

Men with a diagnosed seminoma, men with a diagnosed non-seminoma, both after orchiectomy and before adjuvant therapy, and men with proven paternity in the 2 previous years.

MAIN OUTCOME MEASURE(S)

Rate of nuclear apoptotic sperm DNA fragmentation as assessed by TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling) assay, classified as positive (with DNA fragmentation) or negative (without DNA fragmentation).

RESULT(S)

Of the 48 men with testicular cancer included in the study, 29 (60.4%) presented a non-seminoma and 19 (39.6%) a seminoma. Patients with non-seminoma presented with lower progressive sperm motility than the control group (57.4% and 66.3%, respectively), but both were still within normal ranges. Sperm concentration was lower in seminoma (31.2 x 10(6)/mL) and in non-seminoma (20.6 x 10(6)/mL) when compared with the control group (78.1 x 10(6)/mL), but values did not differ between the two testicular cancer groups. Sperm morphology was lower in patients with non-seminoma than in the control group (10% and 13.1%, respectively). Results for sperm nuclear apoptotic DNA fragmentation (mean; standard deviation) were 12.6%; 4.5% for the control group, 12.2%; 5.5% for the non-seminoma group, and 12.5%; 6.4% for the seminoma group. No differences were found between the three groups.

CONCLUSION(S)

Our results demonstrate that the presence of a seminoma or a non-seminoma is not associated with an increase in sperm apoptotic DNA fragmentation.

Infertility and testis cancer

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

Does histopathologic tumor type or vascular invasion influence spermatogenesis in testicular cancer?

OBJECTIVE

To assess the quality and activity of spermatogenesis in the contralateral healthy testicle at the time of orchiectomy and to assess whether any tumor-related factor such as tumor type or vascular invasion is a risk factor for impaired spermatogenesis.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

Seventy-six patients undergoing orchiectomy for seminoma or nonseminomatous germ cell tumor (NSGCT).

INTERVENTION(S)

Open biopsy of contralateral healthy testicle at the time of orchiectomy.

MAIN OUTCOME MEASURE(S)

Quality of spermatogenesis using median and highest Johnsen score in correlation with histopathologic tumor type, vascular invasion, and serum tumor markers and hormone levels.

RESULT(S)

Contralateral spermatogenesis is reduced in seminomas and in NSGCTs, with median Johnsen scores of 8.9 and 8.6, respectively. Similar results were seen in tumors with vascular invasion (median Johnsen score 8.8 [range 8.2-9.5]) and without vascular invasion (median Johnsen score 8.8 [range 8.1-9.2]). Areas with good-quality spermatogenesis were found in 88.9% of seminoma and 92.5% of NSGCT biopsies.

CONCLUSION(S)

Testicular cancer is associated with impaired spermatogenesis, but neither the histopathologic tumor type nor the presence of vascular invasion correlated with significantly reduced spermatogenesis.

Testicular Cancer. Open Questions: Prevention, Early Diagnosis and Infertility

Testicular cancer is the most common malignancy in men aged 15–35 years. Histologically testicular germ-cell tumors have two main subtypes: pure seminoma and non-seminoma. Knowing the histopathological tumor type and detecting the relevant prognostic factors helps to guide the subsequent therapeutic course.

At present there are no recommendations for testicular cancer screening in healthy young men, even among men showing high risk; however, a testicular cancer should be diagnosed as soon as a young man presents with suggestive signs and symptoms. Furthermore, thanks to highly effective treatments including surgery, chemotherapy, and radiation therapy, it is very important to effectively manage secondary prevention and improve these patients’ quality of life. Secondary prevention of relapses or secondary malignancy onsets should be carried out through a regular follow-up of the patient; in selected cases of positive family history, it is possible to perform genome-wide analyses aiming at searching the genes possibly causing testicular germ-cell tumor in affected first-degree male relatives. Long-term therapies can yield infertility and sexual dysfunction, issues gaining more and more importance from a clinical point of view.

Sperm cryopreservation should be systematically offered to all requiring patients; moreover, screening for gonadal dysfunction should be considered in the follow-up of testicular cancer survivors, with the aim of hormone supplementation in symptomatic patients. (Urologia 2007; 74: 8–14)

Sperm integrity pre- and post-chemotherapy in men with testicular germ cell cancer

BACKGROUND

While (partial) recovery of spermatogenesis, observed by means of standard semen analysis, has been seen in testicular cancer patients after chemotherapy with cisplatin, sperm genomic integrity and its implication for the patient's fertility are poorly understood.

METHODS

Semen and serum from 22 patients treated for testicular cancer were analysed pre- and post-chemotherapy. Besides routine semen analysis, sperm samples were evaluated by computerized karyometric image analysis (CKIA), chromomycin-A3 assay (CMA3, chromatin condensation) and TdT-mediated dUTP nick-end labelling assay (TUNEL, DNA damage). Serum FSH, LH and testosterone concentrations were measured.

RESULTS

Ejaculate volume decreased post-chemotherapy (P<0.05). External sperm characteristics (CKIA morphometry) and sperm counts did not deteriorate after chemotherapy. An improvement in DNA condensation was assessed after chemotherapy (37 versus 50% and 47.5 versus 63.7% for CMA3 and CKIA respectively; both P<0.005); yet a high percentage of TUNEL-positive sperm was found in the samples (21 versus 25% for pre- and post-chemotherapy samples respectively). These values were significantly higher than those of a convenience sample of normozoospermic males attending pre-IVF screening. Serum FSH and LH (IU/l) increased after chemotherapy compared with pretreatment levels (8.1 versus 16.7 and 4.5 vs 6.8; both P<0.05, respectively).

CONCLUSIONS

Despite the improvement in sperm chromatin packaging after chemotherapy, an abnormally high percentage of DNA-damaged sperm was found in these samples. As sperm quality does not reach normal levels after treatment, it remains difficult to outline the best strategy and guidance concerning fertility potential of testicular cancer patients.

Complications of surgery and chemotherapy for testicular cancer

Testicular cancer is a malignancy for which an interdisciplinary approach offers the highest likelihood of cure. In many patients, both chemotherapy and surgery play a prominent role in their care. Although cure can be achieved in a majority of patients, the treatment can occasionally leave the patient with late sequelae. This article discusses the long-term toxicity of curative surgical or cytotoxic therapy for germ cell tumors.

Testicular cancer

PURPOSE OF REVIEW

The purpose of this article is to review the recent clinically relevant literature on testicular cancer.

RECENT FINDINGS

Recent studies suggest that an increased incidence of testicular cancer is due to a birth-cohort effect and secondary to early exposure. Work on identifying tumor prognostic characteristics suggests that proliferation and apoptosis markers as well as serum lactate dehydrogenase isoenzyme 1 (S-LD-1) may have value. Poor-risk patients may benefit from intensive treatment despite a possible increased risk of significant toxicity and treatment related deaths. Studies continue to show the efficacy of radiation for stage I and stage II seminoma, but another study adds to the evidence that adjuvant carboplatin may be an acceptable alternative in stage I disease. Surgical studies suggest that even patients with minimal findings on computed tomography after chemotherapy are at risk for harboring vital tumor. Surveillance is shown to be an acceptable choice for highly compliant patients with early stage disease. Risk factors predictive of bleomycin pulmonary toxicity are proposed. Fertility remains an area of concern.

SUMMARY

Testicular cancer research continues to modify current therapies, increase the understanding of the molecular basis of the disease, and improve the risk stratification of the patient population so as to minimize exposure to treatment-related morbidity and toxicity.

Ethical aspects of cryobiology: responsible applications in biomedicine and in clinical practice

This paper focuses on ethical issues in applications of cryobiology to humans, more particularly in the field of human reproduction and cryosurgery. The paper also provides essential ingredients for the interface of bioethics and cryobiology. For instance, since the 1970s bioethicists have developed four principles to guide the moral evaluation of the 'new medicine.' These are: respect for persons, non-maleficence, beneficence, and justice. In the field of human reproduction major progress was made by the cryopreservation of reproductive material. Still, ethical issues arise whenever partnerships cease to exist (death) or deteriorate (divorce), and decisions have to be made about the disposition of frozen gametes and embryos. Policy-making becomes, then, a prime concern. Examples of regulation in the United States of America, in the United Kingdom, and across Europe are being offered. Cryosurgery remains a field where cryobiologists struggle in their quest for an optimal technique, thus illustrating the need for assessment of safety, efficacy, and benefit to patients. Increasingly, cryobiologists have been joining in the ethical reflection on the use of cryo-technologies. They may further do so by perfecting their ability to identify ethical aspects, by analysing the norms and values at stake, by learning the skill of making the appropriate choices, and by showing their willingness to justify the choices made be it in the inner circle of pairs or publicly.