Effects of cancer on spermatozoa quality after cryopreservation: a 12-year experience

Preservation of male fertility in patients undergoing pelvic irradiation

As the number of cancer survivors increases, so does the demand for preserving male fertility after radiation. It is important for healthcare providers to understand the pathophysiology of radiation-induced testicular injury, the techniques of fertility preservation both before and during radiation, and their role in counseling patients on the risks to their fertility and the means of mitigating these risks. Impaired spermatogenesis is a known testicular toxicity of radiation in both the acute and the late settings, as rapidly dividing spermatogonial germ cells are exquisitely sensitive to irradiation. The threshold for spermatogonial injury and subsequent impairment in spermatogenesis is ~ 0.1 Gy and the severity of gonadal injury is highly dose-dependent. Total doses < 4 Gy may allow for recovery of spermatogenesis and fertility potential, but with larger doses, recovery may be protracted or impossible. All patients undergoing gonadotoxic radiation therapy should be counseled on the possibility of future infertility, offered the opportunity for semen cryopreservation, and offered referral to a fertility specialist. In addition to this, every effort should be made to shield the testes (if not expected to contain tumor) during therapy.

Effect of Malignancy on Semen Parameters

Purpose: We aimed to examine how various types of cancer, classified histologically, affect semen quality. Methods: The study group included 313 patients who were diagnosed with cancer and reached for a sperm cryopreservation before a gonadotoxic treatment (PG-Tx group). Their semen parameters were compared to those of two control groups: (a) individuals who attended a fertility investigation and were found to be above the limit of the lower reference value of the WHO 2010 manual (ARL group), and (b) fertile men, whose semen parameters were obtained from the dataset of the WHO 2020 manual. Results: Semen quality was significantly poorer in the PG-Tx group than in the ARL group. Differences included a 65.6% decrease in concentration, a 12.1% decrease in volume, a 72.7% decrease in total count, and a 33.0%, 22.2%, and 24.7% decrease in total motility, rapid motility, and progressive motility, respectively. Linear regression models comparing the PG-Tx and ARL groups revealed that the maximum reduction in total motility and concentration was in men with germ-cell tumors, whereas the minimum reduction was in hematological tumors. Similarly, all sperm quality parameters were significantly lower in the PG-Tx group than in the fertile-men group (p < 0.0001). Conclusions: While the effect of malignancy on semen parameters is debatable, we found that all examined types of cancer significantly impaired sperm quality parameters. Although the median of most semen parameters of patients with cancer were still in the normal WHO range, their fifth percentile, represents men with a delayed time to pregnancy.

Breast cancer grade and stage do not affect fertility preservation outcomes

PURPOSE

To investigate if breast cancer stage and grade affect fertility preservation outcomes.

METHODS

We performed a retrospective cohort study that included premenopausal women with breast cancer undergoing fertility preservation diagnosed between January 2011 and January 2019. The primary outcome measure was the number of mature oocytes (MII) per antral follicle count (AFC). Secondary outcome measures included total oocytes retrieved, total mature oocytes retrieved, and greater than 10 mature oocytes preserved. Univariate and multivariate models were used to assess the association of low vs. high stage (low stage I-II and high stage III-IV) and grade I vs. grade II/III with each outcome, with adjustment for confounders.

RESULTS

A total of 267 premenopausal breast cancer patients undergoing fertility preservation were included in our study, with the majority presenting with low stage (N = 215, 80.5%), grade II/III (N = 235, 88.1%) disease. Baseline AFC, total gonadotropin dose, days of stimulation, and follicles [Formula: see text] 13 mm on the day of trigger did not differ by stage or grade. After adjusting for age, BMI, and baseline AFC, we found that the mean MII per AFC did not differ by stage (1.0 vs. 1.1, P = 0.3) or grade (1.0 vs. 1.0, P = 0.92). Similarly, total oocytes retrieved, total MII retrieved, and percentage of patients who were able to preserve greater than 10 MII did not differ by breast cancer stage or grade (all P > 0.2).

CONCLUSION

Breast cancer grade and stage do not impact ovarian stimulation or fertility preservation outcome.

Spermatogenesis in Hodgkin's lymphoma patients: a retrospective study of semen quality before and after different chemotherapy regimens

STUDY QUESTION

Is spermatogenesis impairment caused by Hodgkin's lymphoma (HL) itself or by the various treatments?

SUMMARY ANSWER

HL is not itself the main cause of impaired spermatogenesis, which is instead affected by the treatment; the extent of impairment depends on the type of treatment and the number of cycles.

WHAT IS KNOWN ALREADY

Data in the literature are contradictory, although most studies found poor semen quality in HL patients prior to treatment. The impact of therapy on spermatogenesis depends on the type of treatment, but the time needed to recover testicular function following treatment with chemotherapeutic agents inducing azoospermia is unknown.

STUDY DESIGN, SIZE, DURATION

In a retrospective study, the semen parameters of 519 patients (504 with sperm and 15 who were azoospermic) were investigated.HL patients were analysed before therapy. A longitudinal study was also conducted of semen quality in 202 patients pre- and post-ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) at T0 (baseline) and 6 (T6), 12 (T12) and 24 (T24) months after the end of treatment, and of 42 patients pre- and post-BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone), COPP/ABVD (cyclophosphamide, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, vinblastine and dacarbazine), OPP/ABVD (vincristine, procarbazine, prednisone, doxorubicin, bleomycin, vinblastine and dacarbazine) or MOPP (mechlorethamine, vincristine, procarbazine and prednisone) and inguinal radiotherapy at different observation times (from T0 to 16 years after treatment).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Semen parameters were examined according to World Health Organization 2010 criteria, evaluating sperm concentration, total sperm number, progressive motility and morphology.

MAIN RESULTS AND THE ROLE OF CHANCE

Our data, which pertain to the largest caseload reported to date, indicate that 75% of HL patients are normozoospermic prior to treatment. The results from the HL patients studied pre- and post-therapy demonstrate that spermatogenesis recovery depends on the therapeutic regimen used. After ABVD, there was a statistically significant decrease in sperm concentration and total sperm number at T6 and T12 (P < 0.001; P < 0.01, respectively). There was a significant drop in progressive motility (P < 0.001) and a significant increase in abnormal forms (P < 0.01) at T6. The differences in sperm concentration, total sperm number and abnormal forms at T0 and T24 were not statistically significant, indicating that sperm quality had returned to pre-therapy values. The most interesting data in terms of patient management arise from the study of azoospermia induced by other chemotherapeutic agents. A high number of BEACOPP, COPP/ABVD, OPP/ABVD or MOPP cycles (≥6) induced a permanent absence of sperm in the seminal fluid, while even following a low number of cycles (<6), spermatogenesis only recovered after 3-5 years and semen quality was highly impaired.

LIMITATIONS, REASONS FOR CAUTION

The study type (retrospective) and the low caseload and varying time of the follow-up do not permit any firm conclusions to be drawn about the recovery of spermatogenesis after BEACOPP or other combined therapies, or the identification of any risk factors for testicular function in treated patients.

WIDER IMPLICATIONS OF THE FINDINGS

The pretreatment semen parameters of HL patients in this study were better than some results reported in the literature, with a higher percentage of normozoospermic patients. Strengths of this study were the large caseload of HL patients and a high degree of consistency in semen analysis, as all parameters were assessed in the same laboratory. Following the azoospermia induced by different chemotherapeutic protocols, spermatogenesis may take several years to recover. Awareness of this issue will enable oncologists to better inform patients about the possibility of recovering fertility post-treatment and also demonstrates the importance of semen cryobanking before beginning any cancer treatment.

STUDY FUNDING/COMPETING INTERESTS

Supported by a grant from the Italian Ministry of Education and Research (MIUR-PRIN) and the University of Rome 'La Sapienza' Faculty of Medicine. The authors have no conflicts of interest.

Review and follow-up of patients using a regional sperm cryopreservation service: ensuring that resources are targeted to those patients most in need

Are all patients undergoing chemotherapy for long-term sperm banking at risk of permanent sterility? Male fertility is generally lower in men with cancer and all patient groups are at risk of azoospermia. Careful management is required to ensure that samples are not stored for excessively long periods should they not be required. A retrospective analysis of 1688 patient records and prospective recall of patients for semen testing were performed. Pre-therapy fertility was compared with a group of pre-vasectomy patients as a comparator. Those who fail to bank spermatozoa, rates of disposal of samples and the utilization in assisted reproduction were also examined. Sperm quality was poorest in testicular cancer (TC) patients followed by those with Hodgkin's lymphoma (HL) prior to treatment. Post-therapy data were available in 376 patients (42%). Sperm number was lowest (and azoospermia highest at 77%) in patients with HL treated with regimens other than adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). Non-HL NHL and leukaemic patients had similarly high rates of azoospermia at 46 and 55%. HL patients treated with ABVD (11%) and TC patients (9.7%) had the lowest rates of azoospermia. Azoospermia was seen in every treatment group except for TC patients receiving carboplatin. Only 45 patients used their samples in ART (4.5%) in 10 years. Little is known about the fertility status of the patients not coming forward for follow-up testing, those conceiving naturally, those with no intention of conceiving and some which may have psychological reasons for not attending. In conclusion, virtually all patients undergoing chemotherapy are potentially at risk of temporary or permanent infertility. However, as uptake and utilization of stored material remain low, sperm banks should be carefully managed to ensure that resources are targeted to the patients most in need.

Coping Styles of Female Adolescent Cancer Patients with Potential Fertility Loss

PURPOSE

The purpose of this qualitative study was to assess the coping styles of female adolescent cancer patients regarding potential loss of fertility. Expectations and desires for the future, coping styles in typical adolescence, and coping styles when faced with potential loss of fertility due to cancer treatment are discussed.

METHODS

Female adolescents diagnosed with cancer aged 12-18 years at study (N=14) were administered a 10-item values clarification tool to pilot test the readability and relevance of the items on reproductive concerns, followed by a cognitive debriefing interview asking participants how they would respond to each item. These qualitative responses were assessed for coping style type using the constant comparative approach.

RESULTS

All adolescent participants reported having a strong desire for biological children in the future. Reactions to questions regarding the loss of fertility fell into two categories of coping styles: emotion-focused coping or problem-focused (engagement) coping. Within emotion-focused coping, there were three distinct styles: externalizing attribution style, internalizing attribution style, and repressive adaptation. Problem-focused coping adolescents displayed optimism.

CONCLUSION

Successful interventions aimed at promoting adaptive coping styles should seek to uncover adolescents' values about future parenthood and reproduction. Development of an age-appropriate assessment to stimulate dialogue regarding fertility and initiate an adolescent's cognitive processing of potential fertility loss is warranted.

Congruence of reproductive concerns among adolescents with cancer and parents: pilot testing an adapted instrument

OBJECTIVE

To identify whether a health-related quality of life (HRQoL) instrument intended to capture reproductive concerns is sensitive and appropriate for adolescent patients with cancer.

METHODS

Pilot testing was completed by administering a 10-item instrument designed to identify reproductive concerns of female adolescent patients with cancer aged 12-18. Parents were also asked to predict their daughters' responses. Fourteen patients and parents participated. The main outcome measures were language, relevance, accuracy, sensitivity, and missing content regarding the HRQoL instrument. Two pediatric hospitals and 1 local support group for patients and survivors served as the setting for this study.

RESULTS

The majority of parents provided inaccurate predictions of their daughters' responses regarding their reproductive concerns. Overall, parents underestimated their daughters' concerns because the majority of adolescents reported a strong desire for future parenthood whereas parents expected their daughters to be satisfied with survivorship.

CONCLUSIONS

Adolescent patients with cancer have strong reproductive concerns; however, this may not be captured on current HRQoL instruments and may be further neglected due to parents' unawareness. Discussions should be encouraged with adolescent patients before beginning treatment regarding their concerns and values about parenting in the future and cannot rely on parent-proxy reports.

Sperm banking and the cancer patient

The current concepts, recommendations, and principles of sperm banking as it pertains to the comprehensive care of young men of reproductive age with cancer are reviewed. Obstacles to sperm banking are addressed as well as future directions for fertility-preserving technologies. All cancer therapies-chemotherapy, radiation, and surgery-are potential threats to a man's reproductive potential. In addition, cancer itself can impair spermatogenesis. Thus, sperm cryopreservation prior to initiating life-saving cancer treatment offers men and their families the best chance to father biologically related children and should be offered to all men with cancer before treatment. Better patient and provider education, as well as deliberate, coordinated strategies at comprehensive cancer care centers are necessary to make fertility preservation for male cancer patients a priority during pretreatment planning.

Seminal expression of NY-ESO-1 and MAGE-A4 as markers for the testicular cancer

Testicular germ cell tumours (TGCTs) are the most common malignancies in Caucasian young men and their incidence has increased over the past decades. However, a non-invasive test allowing an early diagnosis of TGCT often proves inaccurate. We have previously shown that two Cancer-Testis Antigens (CTA), namely MAGE-A4 and NY-ESO-1, were expressed by TGCT. As exfoliation of carcinoma in situ (CIS) cells or tumour germ cells from testis into seminal fluid can occur, here we studied the expression of the 2 CTA in semen smears of patients with testicular cancer in comparison with healthy men. Using semen smears from healthy controls (n = 65) and patients diagnosed for testicular tumour (n = 57) and immunological staining, we observed expression of MAGE-A4 and NY-ESO-1 proteins in seminal fluid exfoliated cells. We found a highly statistically significant difference in the ratios of stained cells to the total number of round cells between testicular cancer patients and healthy controls. Multivariable analysis, including sperm parameters and immunostaining on sperm smears, shows the improvement. This technique can provide towards testicular cancer diagnosis when it is included in the current testing regime. However, the fact that expression of these markers was not restricted to foetal germ cells led to detection in the semen of a number of healthy subjects. Although the detection of these CTA could be useful to characterize the sub-type of individual TGCTs better, we stress here that the false positive rate precludes the exclusive employment of these CTA for the early detection of testicular neoplasia.

Intracytoplasmic sperm injection (ICSI) using cryopreserved sperm from men with malignant neoplasm yields high pregnancy rates

OBJECTIVE

To investigate the efficacy of IVF-intracytoplasmic sperm injection (ICSI) in patients who cryobanked semen before cancer treatment.

DESIGN

Retrospective consecutive study.

SETTING

University-based IVF unit.

PATIENT(S)

One hundred eighteen couples undergoing IVF-ICSI using pretreatment frozen sperm.

INTERVENTION(S)

Treatment follow-up.

MAIN OUTCOME MEASURE(S)

Semen parameters and clinical pregnancy rates.

RESULT(S)

One hundred eighteen couples underwent 169 IVF cycles using pretreatment cryopreserved sperm; the average sperm count was 66.5 x 10(6)/mL, and the average motility was 45.6%. Post-thaw sperm average density was 40.9 x 10(6)/mL with 14.2% motility. The clinical pregnancy rate was 56.8% per retrieval; 96 pregnancies were achieved, resulting in 126 children born and 11 spontaneous abortions. Patients with prostate cancer had the worst semen parameters before sperm banking and the lowest clinical pregnancy rates.

CONCLUSION(S)

IVF-ICSI is the recommended treatment for most couples with cryopreserved sperm for male cancer. High pregnancy and delivery rates after IVF-ICSI using cryopreserved sperm from patients with cancer should encourage all reproductive-age males to cryobank semen immediately after diagnosis; physicians should discuss this and advise freezing multiple samples before treatment.

Sperm banking for adolescent and young adult cancer patients: sperm quality, patient, and parent perspectives

BACKGROUND

Infertility is often a complication for adolescent and young adult males who receive cancer therapy, a problem that might be averted through using cryopreserved sperm. We aim to evaluate feasibility of offering newly diagnosed patients the opportunity to bank sperm and, to determine the beliefs and decision-making processes of patients and their parents who considered sperm banking.

PROCEDURE

Eligible patients and parents were approached and offered sperm cryopreservation. Semen samples from patients who sequentially attempted sperm banking were analyzed. Questionnaires were then administered to patients and parents who had been approached about sperm banking.

RESULTS

Semen samples from 68 patients were analyzed. Nine patients were azoospermic; all had been pre-treated with chemotherapy. Fifty patients completed the questionnaire. Parent and patient made the decision together to bank 80% of the time. All sons who attempted to bank and their parents felt they had made the right decision, including those who attempted but failed.

CONCLUSIONS

Viable sperm can be collected successfully from adolescent and young adults who are newly diagnosed with cancer. Semen quality was dramatically reduced by one course of gonadotoxic therapy. Parents and patients want information regarding sperm cryopreservation early. Parents appear to play an important role in the decision to sperm bank. We recommend sperm banking be offered to all eligible patients.

[Is there an association between sperm normal morphology and their kinetic displacement?]

OBJECTIVE

To evaluate if there exist an association between the % of normal forms and the kinetic characteristics in human spermatozoa

MATERIAL AND METHODS

A retrospective study was performed to analyze semen samples of 203 patients by Computer Assisted Semen Analysis. Sperm morphology was evaluated by the aid of a micrometric objective according to strict criteria. Only the patients presenting >20 x 106 sperm/ml and > 50% of progressive motility were included. Data from 168 patients were divided according to the % of normal forms in three groups a) <4% (n=22), b) between 4-13% (n=89) and c) >14% (n=57). Data collected among groups were compared. In order to select a motile sperm population 35 samples were treated by a discontinuous gradient and the % of normal forms as well as motility parameters evaluated before and after selection.

RESULTS

The kinetic analysis showed that sperm concentration, the % of motile and rapid spermatozoa (>25 microm/s) as well as the average path velocity (VAP) and the lateral head displacement (LHD) were increased in association with the % of normal spermatozoa presenting the lowest values in the group <4% with respect to the > or = 14% group, (p<0.05). Linearity (LIN) remained constant among groups. Kinetic parameters and sperm morphology were significantly increased (p<0.0001) in the selected samples Results showed that the use of gradients even in teratozoospermic samples improves significantly the % of normal forms respect to baseline values (p<0.0002).

CONCLUSIONS

Our results would support the hypothesis that morphologically better spermatozoa would be associated with those with better movement parameters measured in an objective way. In this manner we could suggest that in vivo the best spermatozoa would comprise one "elite" in the journey through the fertilization site.

American Society of Clinical Oncology recommendations on fertility preservation in cancer patients

PURPOSE

To develop guidance to practicing oncologists about available fertility preservation methods and related issues in people treated for cancer.

METHODS

An expert panel and a writing committee were formed. The questions to be addressed by the guideline were determined, and a systematic review of the literature from 1987 to 2005 was performed, and included a search of online databases and consultation with content experts.

RESULTS

The literature review found many cohort studies, case series, and case reports, but relatively few randomized or definitive trials examining the success and impact of fertility preservation methods in people with cancer. Fertility preservation methods are used infrequently in people with cancer.

RECOMMENDATIONS

As part of education and informed consent before cancer therapy, oncologists should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists. Clinician judgment should be employed in the timing of raising this issue, but discussion at the earliest possible opportunity is encouraged. Sperm and embryo cryopreservation are considered standard practice and are widely available; other available fertility preservation methods should be considered investigational and be performed in centers with the necessary expertise.

CONCLUSION

Fertility preservation is often possible in people undergoing treatment for cancer. To preserve the full range of options, fertility preservation approaches should be considered as early as possible during treatment planning.

Successful spouse pregnancy of male patients with severe aplastic anemia and chronic myelogenous leukemia using spermatozoa banked prior to bone marrow transplantation and using the ICSI procedure: case reports

PURPOSE

To report two cases of successful spouse pregnancies which were conceived with long-term cryopreserved spermatozoa that had been collected prior to the male patients receiving a bone marrow transplant.

METHODS

The first case is the pregnant wife of a 25-year-old man with chronic myelogenous leukemia, whose semen was collected before bone marrow transplant and then cryopreserved, thawed, and then injected into the wife's eggs via ICSI. The second case is a 28-year-old man with severe aplastic anemia who became a father after his wife's eggs were fertilized via ICSI with thawed spermatozoa.

RESULTS

These two cases were achieved pregnancies.

CONCLUSIONS

These cases support research that men with malignancy have the chance of fathering their own genetic children. Therefore, it is important to increase the awareness of clinicians, oncologists, and patients to the new developments in preserving fertility for cancer patients.

Kryokonservierte humane Spermadepots

To determine the effect of long-term storage on cryopreserved human sperm, 238 individual samples from 34 cryopreserved sperm deposits that had been collected between 1976 and 1989 were evaluated at regular intervals. The material was from 34 patients, 18 of whom suffered from underlying malignant disease. Every 3 years a sample from each deposit was thawed for microscopic analysis. During the course of the storage period limited to a maximum of 21 years, all ejaculate parameters had deteriorated in comparison to fresh semen. Quantitative motility was the most sensitive parameter with a decrease of ca. 80%. Sperm density decreased hardly at all. The parameters of the criteria investigated did not decrease linearly or proportionally with the storage duration, but rather more directly after the freezing process or within the first 3 years. These changes became increasingly smaller as the storage time lengthened. Almost all of the deposits exhibited adequate quality at all times during storage. Consequently, 21-year permanent frozen storage in liquid nitrogen is safe regarding aspects of spermatology.

Feasibility of refreezing human spermatozoa through the technique of liquid nitrogen vapor

OBJECTIVE

To assess the feasibility of refreezing human semen using the technique of liquid nitrogen vapor with static phases.

MATERIALS AND METHODS

Twenty samples from 16 subjects who required disposal of their cryopreserved semen were thawed, corresponding to 6 cancer patients and 10 participants in the assisted reproduction (AR) program. Samples were refrozen using the technique of liquid nitrogen vapor with static phases, identical to the one used for the initial freezing, and thawed again after 72 hours. We assessed the concentration of motile spermatozoa, total and progressive percent motility and spermatic vitality, according to criteria of the World Health Organization (WHO), as well as spermatic morphology according to the strict Kruger criterion, after the first and after the second thawing.

RESULTS

We observed a significant decrease in all the parameters evaluated between the first and the second thawing. Median values for the concentration of motile spermatozoa decreased from 2.0x10(6)/mL to 0.1x10(6)/mL (p < 0.01); total percent motility from 42% to 22.5% (p < 0.01); progressive percent motility from 34% to 9.5% (p < 0.01); vitality from 45% to 20% (p < 0.01); and morphology from 5% to 5% (p = 0.03). There was no significant difference in the spermatic parameters between the cancer and assisted reproduction groups, both after the first and after the second thawing. We observed that in 100% of cases there was retrieval of motile spermatozoa after the second thawing.

CONCLUSION

Refreezing of human semen by the technique of liquid nitrogen vapor allows the retrieval of viable spermatozoa after thawing.

Effect of selenium-induced oxidative stress on the cell kinetics in testis and reproductive ability of male mice

OBJECTIVE

The present study evaluated the role of experimental oxidative stress (induced by feeding diets with different concentrations of selenium [Se], a trace nutrient and potent antioxidant) on male reproductive activity in mice.

METHODS

To create different levels of oxidative stress in male mice, three diets with different levels of Se were fed to different groups for 8 wk. Mice in group 1 were fed a yeast-based diet, which is considered a Se-deficient diet (0.02 ppm). Mice in groups 2 and 3 were fed with an Se-deficient diet supplemented with 0.2 and 1 ppm Se as sodium selenite, respectively.

RESULTS

After completion of the feeding schedule, a significant decrease in Se levels were observed in Se-deficient mice (group 1), whereas Se levels greatly increased in the Se-excess mice (group 3). Glutathione peroxidase activity was greatly decreased in the liver and testis in group 1, whereas glutathione-S-transferase activity was significantly increased in the testis. No significant change was found in activities of glutathione peroxidase and glutathione-S-transferase in group 3 compared with group 2. Cell kinetics showed a significant decrease in the number of pachytene spermatocytes and young and mature spermatids in group 1 compared with group 2. No appreciable change was observed in the germinal cell population in group 3. A significant decrease in sperm number was observed in group 1 compared with group 2. No change in these parameters was observed in group 3. The fertility status of mice in terms of percent fertility and litter size also exhibited a significant decrease in the reproductive ability of group 1. No change in these parameters was observed in group 3 compared with group 2.

CONCLUSION

The present results clearly demonstrate the effect of oxidative stress generated by feeding different concentrations of Se on cell kinetics in the testis and, hence, its effect on the reproductive ability of male mice.

Sperm cryopreservation for male patients with cancer: an epidemiological analysis at the University of Pennsylvania

Many cancers strike young males who have not yet started or completed families. Since cancer treatments such as chemotherapy and radiation can irreversibly affect spermatogenesis, sperm cryopreservation is an important option for storing male reproductive potential. In this report, we review our database of 10 years of experience with cryostorage for male cancer patients. We assess types of cancer, timing of collection, sperm quality, and utilization for reproductive purposes. We also report specimen disposal and rates of patient death. There were a total of 164 oncology patients electing to freeze sperm at our institution during the study period. Types of cancer were varied, with testicular cancer, Hodgkin's lymphoma, leukemia, and gastrointestinal cancers comprising the largest groups. Evaluation of semen parameters for these groups revealed that oligospermia, even prior to initiation of cancer therapy, was common. Sperm counts, motility, and morphology did not differ by type of cancer. Interestingly, less than 5% of patients utilized their specimens for reproductive purposes. Seven insemination cycles yielded no pregnancies, while one of two IVF attempts and the single ICSI case were successful. In conclusion, the epidemiological review of our database suggests that sperm cryostorage for fertility preservation in male cancer patients is under-utilized. Additionally, there is minimal use of cryopreserved specimens for reproductive purposes. We speculate that this under-utilization may be due to the paucity of reports regarding reproductive outcome after freezing. It is our objective to provide a compilation of data that will prove useful to both physicians and patients who are considering sperm cryopreservation.

Fertility after cancer: a prospective review of assisted reproductive outcome with banked semen specimens

OBJECTIVE

To examine the outcome of assisted reproduction techniques (ART) using cryopreserved semen from patients with cancer.

DESIGN

Prospective.

SETTING

Therapeutic semen banking program at a tertiary healthcare center.

PATIENT(S)

Twenty-nine men with cancer who cryopreserved their sperm before treatment at our facility from 1982 to 2001 and withdrew their samples for assisted reproduction (IUI, IVF, or intracytoplasmic sperm injection [ICSI]).

INTERVENTION(S)

Sperm bank records were used to identify the patients. Information on fertility potential indices was obtained from medical records and through interviews. Of the 29 patients, 9 had testicular cancer, 12 had Hodgkin's disease, and 8 had other types of cancer.

MAIN OUTCOME MEASURE(S)

Pregnancy and live births.

RESULT(S)

A total of 87 ART cycles (42 IUI, 26 IVF, and 19 ICSI) was performed. Of those cycles, 18.3% resulted in pregnancy (7% IUI, 23% IVF, and 37% ICSI), and 75% of the pregnancies resulted in a live birth (100% IUI, 83% IVF, and 57% ICSI). There was no significant difference in the outcomes when the results were stratified by type of ART and malignancy. None of the 11 infants who were born had congenital anomalies.

CONCLUSION(S)

Our findings emphasize the need for physicians to discuss the issue of semen cryopreservation with all men of reproductive age who have cancer before antineoplastic therapy is started.

Fertility in men with testicular germ cell tumors

OBJECTIVE

To assess the prevalence of fertility or infertility in men before and after treatment for unilateral testicular cancer. The results were compared with the lifetime prevalence of infertility in the general population (20%-28%).

DESIGN

Survey.

SETTINGS

University referral center for testicular cancer.

PATIENT(S)

Two hundred twenty-six patients treated for testicular cancer.

INTERVENTION(S)

Questionnaire on fertility and fertility-related factors before and after treatment of disease.

MAIN OUTCOME MEASURE(S)

Prevalence of fertility before and after treatment for testicular cancer.

RESULT(S)

Before the cancer was diagnosed, 79 (66%) of 120 couples who attempted to conceive succeeded within 1 year. After treatment, 38 (43%) of 88 couples conceived within 1 year. Seven couples used cryopreserved sperm to conceive a child after treatment. The different treatment modalities did not significantly influence the outcome of patients' wish for children. Congenital malformations were recorded in approximately 4% of the children born before or after treatment.

CONCLUSION(S)

Although the majority of the patients with testicular cancer have a fulfilled wish with regard to children, it seems to be more difficult to father a child after treatment compared with the case in the general population. Because it is not possible to predict which patient will have fertility problems after treatment, cryopreservation should be offered to every testicular cancer patient. An increased risk for congenital malformations was not observed.

Sperm banking and rate of assisted reproduction treatment: insights from a 15-year cryopreservation program for male cancer patients

BACKGROUND

Semen cryostorage remains the only proven method to preserve fertility in men with cancer. However, the necessity and the justification of banking spermatozoa have been questioned because it has been reported that only a small percentage of patients are referred for assisted reproductive technologies using frozen semen.

METHODS

A 15-year cryopreservation program involving 776 men with malignant diseases who were referred to the study institution for semen cryopreservation before proceeding with chemotherapy and/or radiotherapy was reviewed. Data regarding cancer diagnosis, age, semen quality, and use of frozen semen were analyzed.

RESULTS

Sperm banking was not performed for 90 of the 776 subjects (11.6%) because of azoospermia. Sperm quality was reduced in men with testicular carcinoma. To date, 36 of the 686 patients who had banked spermatozoa (5.2%) have attended the clinic for assisted conception treatments using frozen spermatozoa. Cumulative rates related to the use of frozen semen at 4, 8, and 12 years were 4.5%, 8.7%, and 11.8%, respectively. Relevant factors demonstrated to be significantly associated with a lower probability of using frozen material were a younger age at the time of cryostorage and a diagnosis of testicular carcinoma.

CONCLUSIONS

The rate of referral for assisted reproductive techniques in patients who have banked their semen is low but tends to rapidly increase extending the length of follow-up. The cumulative percentage of use is at least above 10% but a longer follow-up is required to draw definitive conclusions. A diagnosis of testicular carcinoma is associated with a lower rate of use when compared with other cancers. Cancer 2003;97:1624-9.

Effect of cancer therapy on pituitary-testicular axis

Treatment with cytotoxic chemotherapy and radiotherapy is associated with significant gonadal damage in men. Alkylating agents, such as cyclophosphamide and procarbazine, are the most common agents implicated. The vast majority of men receiving procarbazine-containing regimens for the treatment of lymphomas are rendered permanently infertile. Treatment with adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) appears to have a significant advantage in terms of testicular function, with a return to normal fertility in the vast majority of patients. Cisplatin-based chemotherapy for testicular cancer results in temporary azoospermia in most men with a recovery of spermatogenesis in about 50% after 2 years and 80% after 5 years. There is also evidence of chemotherapy-induced Leydig cell impairment in a proportion of these men, although this appears to be of no clinical significance in the majority of patients. The germinal epithelium is very sensitive to radiation-induced damage with changes to spermatogonia following as little as 0.1 Gy, and permanent infertility after fractionated doses of 2 Gy and above, whereas clinically significant Leydig cell impairment occurs rarely with doses of less than 20 Gy.

Comprehensive office evaluation in the new millennium

The success of a comprehensive office-based evaluation of male-factor infertility depends on the physician's thorough understanding of risk assessment in the history, identification of pertinent physical examination findings, and correct assessment of laboratory data. Office-based ultrasonographic techniques have already increased the urologist's ability to visualize suspected anatomic abnormalities, and the use of functional tests of sperm has given greater depth to the limited, but essential, prognostic capabilities of the routine semen analysis.

Fertility preservation and management of gonadal failure associated with lymphoma therapy

Treatment with cytotoxic chemotherapy and radiotherapy is associated with significant gonadal damage in men and women. The likelihood of gonadal failure following cytotoxic chemotherapy is dependent on the drug and dose, and in women there is also an effect of age at treatment. Irradiation of the testes or ovaries, either directly or indirectly, is also a significant cause of gonadal dysfunction, and the potential to recover from damage is clearly related to the radiation dose received. Several methods of preserving gonadal function during potentially sterilizing treatment have been considered. At present, sperm banking remains the only proven method in men, although hormonal manipulation to enhance recovery of spermatogenesis and cryopreservation of testicular germ cells are possibilities for the future. Transposition of the ovaries to allow better shielding during radiotherapy is of use in some women, and the prospect of cryopreservation and reimplanation of ovarian tissue appears to be promising.

Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors

PURPOSE

The goal of this study was to survey male patients aged 14 to 40 years at diagnosis and recently treated in two cancer centers to determine their knowledge, attitudes, and experiences regarding cancer-related infertility and sperm banking.

PATIENTS AND METHODS

A postal survey about cancer-related infertility and sperm banking was offered to 904 men diagnosed with cancer within the previous 2 years. Eight percent opted out of the study. The others were sent the survey, with a cover letter stating elements of informed consent.

RESULTS

Although the return rate was only 27%, yielding a sample of 201 men, responders did not differ significantly from nonresponders by institution, age, ethnicity, or cancer site. Overall, 51% of men wanted children in the future, including 77% of men who were childless at cancer diagnosis. Despite some anxieties about their own survival and risks to their children's health, men felt that the experience of cancer increased the value they placed on family closeness and would make them better parents. Only 60% of men recalled being informed about infertility as a side effect of cancer treatment, and just 51% had been offered sperm banking. Those who discussed infertility with their physicians had higher knowledge about cancer-related infertility and were significantly more likely to bank sperm. Only 24% of men banked sperm, including 37% of childless men. Lack of information was the most common reason for failing to bank sperm (25%).

CONCLUSION

All men who are about to receive cancer treatment that could impair fertility should be counseled about such side effects and given adequate information to make an informed decision about banking sperm.

Oncologists' attitudes and practices regarding banking sperm before cancer treatment

PURPOSE

The goal of this study was to survey oncologists in three different practice settings to determine their knowledge, attitudes, and practices regarding referring patients to bank sperm before cancer treatment.

METHODS

A postal survey about knowledge, attitudes, and practices regarding banking sperm before cancer treatment was sent to 718 oncology staff physicians and fellows at two cancer centers and at sites in a Community Clinical Oncology Program.

RESULTS

The return rate was 24% and did not differ by institution, oncologic specialty, or sex. Fellows were significantly more likely to participate (37%) than staff physicians (20%). Ninety-one percent of respondents agreed that sperm banking should be offered to all men at risk of infertility as a result of cancer treatment, but 48% either never bring up the topic or mention it to less than a quarter of eligible men. Neither greater knowledge about sperm banking nor seeing large numbers of eligible men yearly increased the likelihood of discussing the option. Barriers cited included lack of time for the discussion, perceived high cost, and lack of convenient facilities. Oncologists reported they would be less likely to offer sperm banking to men who were homosexual, HIV-positive, had a poor prognosis, or had aggressive tumors. Oncologists overestimated the costs of sperm banking and the number of samples needed to make cryopreservation worthwhile.

CONCLUSION

Sperm banking should be offered as an option to all men at risk of infertility because of their cancer treatment. Clearer practice standards could help oncologists increase their knowledge about sperm banking and avoid dependence on biased patient selection criteria.

Sperm cryopreservation for men with nonmalignant, systemic diseases: a descriptive study

Cytotoxic drugs and immunosuppressive therapies are used to treat patients with nonmalignant, nontesticular systemic diseases. These therapies can permanently suppress spermatogenesis. Sperm cryopreservation before treatment theoretically could give these men the opportunity to achieve a pregnancy with a woman later in life when the couple decides to do so. However, it is not known whether pretreatment sperm quality in these men is good enough to be used for assisted reproductive techniques. The main objective of this study was to determine the usefulness of cryopreservation in this patient population by: 1) assessing their pretreatment semen quality (eg, count, motility, and motion kinetics) and comparing it with that of healthy donors before and after cryopreservation; 2) comparing patients' pretreatment semen characteristics with World Health Organization reference values for normal sperm; and 3) examining the differences in semen parameters among patient groups. Semen specimens were obtained from 25 healthy donors and from 23 patients with a variety of disorders (12 had autoimmune disorders, 4 had kidney disorders, 3 had diabetes, 2 had ulcerative colitis, and 2 had heart transplants). All patients, except those with diabetes, required immunosuppressive or cytotoxic therapy. Although the pretreatment quality of the semen of these patients was not as good as that of donors, semen samples were within the normal reference range of the World Health Organization. No statistically significant differences in sperm parameters were found within the 4 patient groups except for those with diabetes (n = 3), who showed poorer sperm counts (P < .04). However, no conclusive evidence can be reached due to the small sample size. Our results indicate that pretreatment semen quality in these patients is adequate for reproductive techniques. We believe that cryopreservation should be offered to patients of reproductive age with disease or treatment regimens that may cause infertility.

Long-term outcomes of elective human sperm cryostorage

BACKGROUND

Sperm cryopreservation allows men with threatened fertility to preserve their progenitive potential, but there is little data on long-term outcomes of elective sperm cryostorage programmes.

METHODS AND RESULTS

Over 22 years, 930 men sought semen cryostorage in a single academic hospital, of which 833 (90%) had spermatozoa cryostored. Among 692 (74%) men surviving their illness, sperm samples were discarded for 193 (21% of all applicants, 28% of survivors) and cryostored spermatozoa were used for 64 men (7% of all applicants, 9% of survivors) in 85 treatment cycles commencing at a median of 36 months post-storage (range 12-180 months) with nearly 90% of usage started within 10 years of storage and none after 15 years. Pregnancy was most efficiently produced by intracytoplasmic sperm injection (median three cycles) compared with conventional IVF (median eight cycles) or artificial insemination (median more than six cycles; P < 0.05). A total of 141 (15%) of men had died and of these, 120 (85% of those dying) had their spermatozoa discarded; requests to prolong cryostorage were received from relatives of 21 men (2% of all applicants, 15% of deceased) of which three cases had spermatozoa transferred for use with no pregnancies reported. Sperm concentration was lower for all cryostorage groups compared with healthy sperm donor controls (P < 0.05). Following orchidectomy, men with testicular cancer had sperm density approximately half that of all other groups of men seeking cryostorage (P < 0.05), the lowering attributable to removal of one testis rather than in defects in spermatogenesis.

CONCLUSION

Elective sperm cryopreservation is an effective, if sparsely used, form of fertility insurance for men whose fertility is threatened by medical treatment and is an essential part of any comprehensive cancer care programme.

Differential production of reactive oxygen species by subsets of human spermatozoa at different stages of maturation

BACKGROUND

Reactive oxygen species (ROS)-mediated damage to human spermatozoa has been implicated in the pathogenesis of male infertility. Although ROS production by human spermatozoa has been extensively studied, the cell-to-cell variation in ROS production by spermatozoa at different stages of maturation has never been investigated.

METHODS

In this study, we determined ROS production by subsets of human spermatozoa at different stages of maturation isolated by density gradient centrifugation of ejaculated spermatozoa obtained from healthy donors and from patients attending a clinic for infertility screening.

RESULTS

Four different fractions were obtained. ROS production was highest in immature spermatozoa with abnormal head morphology and cytoplasmic retention and lowest in mature spermatozoa and immature germ cells (P < 0.01). ROS production was highest in immature spermatozoa from males with abnormal semen parameters compared with donors (P < 0.0001) or patients with normal semen parameters (P = 0.015). ROS production by immature spermatozoa was inversely correlated with the recovery of motile, mature spermatozoa in the high density fraction 4 (P = 0.01).

CONCLUSIONS

The results of this study indicate that there is significant cell-to-cell variation in ROS production in subsets of spermatozoa at different stages of maturation and that oxidative damage of mature spermatozoa by ROS-producing immature spermatozoa during sperm migration from the seminiferous tubules to the epididymis may be an important cause of male infertility.

Characterization of subsets of human spermatozoa at different stages of maturation: implications in the diagnosis and treatment of male infertility

BACKGROUND

Reactive oxygen species (ROS)-induced damage of membrane phospholipids and DNA in human spermatozoa has been implicated in the pathogenesis of male infertility. In this study, variations in ROS production, DNA structure (as measured by the sperm chromatin structure assay) and lipid composition, were studied in human spermatozoa at different stages of maturation.

METHODS

Sperm subsets were isolated by discontinuous density gradient centrifugation of semen samples obtained from healthy donors and from infertility patients.

RESULTS

DNA damage and ROS production were highest in immature spermatozoa with cytoplasmic retention and abnormal head morphology, and lowest in mature spermatozoa. Docosahexaenoic acid and sterol content were highest in immature germ cells and immature spermatozoa, and lowest in mature spermatozoa. The relative proportion of ROS-producing immature spermatozoa in the sample was directly correlated with DNA damage in mature spermatozoa, and inversely correlated with the recovery of motile spermatozoa. There was no correlation between DNA damage and sperm morphology in mature spermatozoa.

CONCLUSIONS

The high levels of ROS production and DNA damage observed in immature spermatozoa may be indicative of derangements in the regulation of spermiogenesis. DNA damage in mature spermatozoa may be the result of oxidative damage by ROS-producing immature spermatozoa during sperm migration from the seminiferous tubules to the epididymis.

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

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

Characteristics of cryopreserved semen from men with lymphoma

PURPOSE

This study compared the pretreatment semen quality in patients with Hodgkin's disease and non-Hodgkin's lymphoma with a group of healthy donors. We also examined the differences in prefreeze and postthaw semen quality among the different stages of Hodgkin's disease.

METHODS

The study included 89 patients with Hodgkin's disease, 18 with non-Hodgkin's lymphoma, and 50 healthy sperm donors.

RESULTS

In patients with Hodgkin's disease, the prefreeze and postthaw semen characteristics were significantly lower than those of the healthy donors. Similar results also were seen in patients with non-Hodgkin's lymphoma. No significant differences in the prefreeze semen quality were seen in patients with different stages of cancer.

CONCLUSION

Patients with Hodgkin's disease and non-Hodgkin's lymphoma in our study had poor semen quality when compared with healthy donors both before and after cryopreservation. As cancer therapy significantly impairs reproductive potential, sperm banking should be offered to these men before the start of their therapy.

Follow-up of sperm concentration and motility in patients with lymphoma

Lymphomas are a group of diseases, prevalent at reproductive age. Fertility is notoriously reduced among lymphoma patients. This study evaluates pre- and post-treatment semen concentration and motility, and factors associated with semen quality deterioration. We followed-up 33 patients with non-Hodgkin's lymphoma or with Hodgkin's disease during the years 1987-1997 who were referred for semen cryopreservation. Pretreatment semen analysis, and hormonal profile were recorded at diagnosis and at least 1 year after completion of the treatment, and compared. Medical records for disease type, disease stage and treatment protocols were related to long-term sperm outcome. Hormonal concentrations were not predictive of post-treatment sperm concentration. In patients with localized disease, initial sperm concentration and motility tended to be preserved, compared with patients with widespread disease (P: = 0. 016). In Hodgkin's disease patients, treatment with the adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) protocol was superior to the mechloretamine, vincristine, procarbazine and prednisone with ABV protocol regarding germinal toxicity (P: = 0.0008). The post-treatment sperm outcome was better in patients treated with local irradiation than in those who did not undergo irradiation (P: = 0.0027). No predictive tools for post-treatment fertility were found and, therefore, every patient with a lymphoma should have his semen cryopreserved at diagnosis.

Semen banking in patients with cancer: 20-year experience

Modern techniques of banking sperm provide an effective way to preserve the option of future fertility for most teenagers and young men diagnosed with a variety of malignancies that will necessitate treatment with chemotherapy, pelvic surgery, or significant radiation doses to the testes. Results of cumulative data collected at the Cleveland Clinic Foundation from patients with testicular cancer, lymphoma, leukemia, sarcoma, carcinoma and other kinds of malignancy have revealed that: (1) pretreatment semen quality (pre-freeze and post-thaw) in patients with cancer is poorer compared with healthy donors; (2) the percentage decline in semen quality (from pre-freeze to post-thaw) in patients with cancer is similar to that of normal donors. This suggested that the effect of cryodamage on spermatozoa from patients with cancer is similar to that of normal donors. (3) The stage of cancer in patients with testicular cancer and Hodgkin's disease shows no relationship to their semen quality. Based on studies conducted at the Cleveland Clinic Foundation, we recommend that sperm cryopreservation be offered to all men of reproductive age who have malignancies. Cryopreservation is safe and inexpensive, and gives patients a chance to establish pregnancies in the future with an assisted reproductive technique.