Sperm cryopreservation in patients with testicular cancer

The effect of gonadal and extragonadal malignant cancers on sperm quality

Background

Many studies have reported that testicular germ cell tumours (TGCTs) give rise to a decrease in sperm production and may further lead to infertility. However, little is known regarding sperm production in extragonadal germ cell tumours (EGCTs). We have studied the differences in the characteristics and sperm quality of patients with testicular cancer and patients with EGCTs.

Methods

We collected and analysed demographic factors, semen parameters, and the disposition of banked sperm.

Results

TGCTs accounted for the majority of malignant cancers compared with EGCTs (83.9% vs. 16.1%, respectively). There were no statistically significant differences in semen volume, pre-freeze concentration, pre-freeze motility, post-thaw concentration, post-thaw motility or recovery rate between patients with TGCTs and those with EGCTs. Both patients with TGCTs and EGCTs showed low pre-freeze and post-thaw sperm concentrations. Men with a seminoma had a higher median level of thaw-sperm motility in their ejaculate than men with non-seminomas. TGCT (67%) and EGCT (72%) patients chose to keep their specimens in storage.

Conclusions

Our study provides evidence that both patients with TGCTs and EGCTs have a high risk for impaired semen quality and gonadal dysfunction. This suggests that oncologists and patients should consider the effects of both TGCTs and EGCTs on fertility among males.

Granulocyte Colony-Stimulating Factor Restored Impaired Spermatogenesis and Fertility in an AML-Chemotherapy Mice Model

Leukemia and treatment of male patients with anticancer therapy (aggressive chemotherapy and/or radiotherapy) may lead to infertility or even permanent male sterility. Their mechanisms of spermatogenesis impairment and the decrease in male fertility are not yet clear. We showed that under acute myeloid leukemia (AML) conditions, alone and in combination with cytarabine (CYT), there was significant damage in the histology of seminiferous tubules, a significant increase in apoptotic cells of the seminiferous tubules, and a reduction in spermatogonial cells (SALL and PLZF) and in meiotic (CREM) and post-meiotic (ACROSIN) cells. In addition, we showed a significant impairment in sperm parameters and fertilization rates and offspring compared to control. Our results showed a significant decrease in the expression of glial cell line-derived neurotrophic factor (GDNF), macrophage colony-stimulating factor (MCSF) and stem cell factor (SCF) under AML conditions, but not under cytarabine treatment compared to control. In addition, our results showed a significant increase in the pro-inflammatory cytokine interleukin-1 (IL-1) alpha in whole testis homogenates in all treatment groups compared to the control. Increase in IL-1 beta level was shown under AML conditions. We identified for the first time the expression of GCSF receptor (GCSFR) in sperm cells. We showed that GCSF injection in combination with AML and cytarabine (AML + CYT + GCSF) extended the survival of mice for a week (from 6.5 weeks to 7.5 weeks) compared to (AML + CYT). Injection of GCSF to all treated groups (post hoc), showed a significant impact on mice testis weight, improved testis histology, decreased apoptosis and increased expression of pre-meiotic, meiotic and post- meiotic markers, improved sperm parameters, fertility capacity and number of offspring compared to the controls (without GCSF). GCSF significantly improved the spermatogonial niche expressed by increased the expression levels of testicular GDNF, SCF and MCSF growth factors in AML-treated mice and (AML + CYT)-treated mice compared to those groups without GCSF. Furthermore, GCSF decreased the expression levels of the pro-inflammatory cytokine IL-12, but increased the expression of IL-10 in the interstitial compartment compared to the relevant groups without GCSF. Our results show for the first time the capacity of post injection of GCSF into AML- and CYT-treated mice to improve the cellular and biomolecular mechanisms that lead to improve/restore spermatogenesis and male fertility. Thus, post injection of GCSF may assist in the development of future therapeutic strategies to preserve/restore male fertility in cancer patients, specifically in AML patients under chemotherapy treatments.

PDE11A gene polymorphism in testicular cancer: sperm parameters and hormonal profile

PURPOSE

Testicular germ cell tumours (TGCTs) is the most common malignancy among young adult males. The etiology is multifactorial and both environmental and genetic factors play an important role in the origin and development of TGCT. Genetic susceptibility may result from the interaction of multiple common and low-penetrance genetic variants and one of the main candidate genes is PDE11A. Many PDE11A polymorphisms were found responsible for a reduced PDE activity in TGCT patients, who often also display impaired hormone and sperm profile. The aim of this study was to investigate testicular function and PDE11A sequence in testicular cancer cases.

METHODS

Semen analysis was performed in 116 patients with unilateral and bilateral sporadic TGCTs and in 120 cancer-free controls. We also investigated hormone profile and PDE11A polymorphisms using peripheral blood samples.

RESULTS

Our data revealed that TGCT patients showed lower testosterone levels, higher gonadotropins levels and worse semen quality than controls, although the mean and the medians of sperm parameters are within the reference limits. PDE11A sequencing detected ten polymorphisms not yet associated with TGCTs before. Among these, G223A in homozygosity and A288G in heterozygosity were significantly associated with a lower risk of testicular tumour and they displayed a positive correlation with total sperm number.

CONCLUSIONS

Our findings highlight the key role of PDE11A in testis and suggest the presence of an underlying complex and fine molecular mechanism which controls testis-specific gene expression and susceptibility to testicular cancer.

A Descriptive Study Exploring Semen Quality Among Indian Cancer Patients

Purpose: To descriptively explore semen quality among Indian men with various types of malignancies. We evaluated semen parameters of male patients referred to our hospital before commencing their cancer treatment. Methods: Four hundred sixty-one male patients who were within the age range of 15-50 years were recruited with diagnosed malignancies. Pre-treatment semen analyses were performed on these patients to collect data on the volume, sperm concentration, motility, and normal forms (morphology). These semen parameters were compared between cancer groups (testicular cancer, hematological cancer, and other cancers). Further comparisons were also drawn to World Health Organization (WHO) semen parameter levels (2010, fifth edition) for normal outcomes. Results: There were no notable variations observed in semen volume (mL) and progressive motility (%) between cancer groups. These parameters were within the WHO normal semen criteria. Differences in normal forms (%) between cancer groups were not observed either; however, they were marginally lower compared with the WHO criteria. Sperm concentration was evidently lower in testicular cancer 34 × 10⁶/mL (IQR: 10.1-60 × 10⁶/mL) compared with hematological cancers 66 × 10⁶/mL (IQR: 23-84.21 × 10⁶/mL) and other cancers (IQR: 27-86.3 × 10⁶/mL). Testicular cancer patients also presented with the largest semen disorder diagnosis (Asthenozoospermia, Oligoasthenozoospermia, Oligozoospermia, and Azoospermia) compared with two other groups. Conclusion: Males with testicular cancer have shown to have lower semen quality between cancer groups and compared with WHO criteria, increasing their likelihood of them being infertile. This study further allows us to understand these outcomes, particularly in the Indian subpopulation, propagating changes in guidelines in oncofertility and medical counseling. Clinical Trials Registry-India number: CTRI/2020/09/027720.

Long-term sperm cryopreservation does not affect post-thaw survival rates

Objective:

To compare cryosurvival rates of human spermatozoa in a prolonged period of cryopreservation.

Methods:

This retrospective study involved 33 cryopreserved semen samples from patients with cancer, between 2002 and 2011. The semen sample was obtained by masturbation and initial semen analysis was performed. The cryoprotectant solution was added and samples were frozen in liquid nitrogen in a slow step-wise process. For thawing, the samples were incubated at 25.0ºC for 15 min, followed by incubation at 36.7ºC for 15 min. The cryosurvival rate (CS) was calculate by CS= [(% total motile sperm post-thaw) x100/(% total motile sperm/tube)]. Each study sample was divided into three aliquots (Study Group; n=23): (I) official patient sample, which was kept cryopreserved for subsequent Assisted Reproduction procedure, cryopreserved between 2002 and 2011; (II) sample destined to post-thaw tests, performed after the sample had been kept cryopreserved for 24 hours; and (III) study sample. Only in 2014, after 3-12 years of cryopreservation, the study samples were thawed and evaluated. To validate the study design, a Validation Group was created including 10 samples obtained between 2014 and 2016, using the same methodology in the study samples. The data was analyzed using the T-test, with a significant p-value of 5%.

Results:

The mean age was 29.93±9.57 years in the Study Group and 21.80±6.49 years in the Validation Group. No significant difference between the Validation and Study Groups was found in the initial semen analysis (p>0.05). After 24 hours of cryopreservation, the cryosurvival rate was 26.11±46.36% in the Study Group and 23.71±57.06% in the Validation Group. Aliquots of the same sample preserved from 3-12 years demonstrated 23.71±57.06% of cryosurvival rate. Thus, no significant difference was found vis-à-vis the cryosurvival rates (p=0.56).

Conclusion:

We concluded that the method introduced in the late 1990s, which enables the removal of debris, potentially toxic elements and generators of reactive oxygen species from the seminal sample before cryopreservation, exhibited efficiency in maintaining the same cryosurvival rate after an extended period.

Acute Myeloid Leukemia Affects Mouse Sperm Parameters, Spontaneous Acrosome Reaction, and Fertility Capacity

Leukemia is one of the most common cancers in patients of reproductive age. It is well known that chemotherapy, used as anti-cancer therapy, adversely affects male fertility. Moreover, the negative effect of leukemia on sperm quality, even before chemotherapy treatment, has been reported. However, the mechanisms behind this disease's effect on sperm quality remains unknown. In this study, we examine the direct effect of leukemia and chemotherapy alone and in combination on sperm parameters and male fertility. For this, we developed an acute myeloid leukemia (AML) mouse model (mice were treated with AML cells C1498 and developed leukemia); these mice then received cytarabine chemotherapy. Our findings reveal a significant reduction in sperm concentration and motility and a significant increase in abnormal morphology and spontaneous acrosome reaction of the sperm following AML and chemotherapy treatment, alone and in combination. We also found a reduction in male fertility and the number of delivered offspring. Our results support previous findings that AML impairs sperm parameters and show for the first time that AML increases spontaneous acrosome reaction and decreases male fertility capacity and number of offspring.

Leukemia and male infertility: past, present, and future

Spermatogenesis is the process of the proliferation and differentiation of spermatogonial stem cells (SSCs) to generate sperm. Leukemia patients show impairment in some of the endocrine hormones that are involved in spermatogenesis. They also show a decrease in semen parameters before and after thawing of cryopreserved samples compared to a control. The mechanisms behind these effects have not yet been described. This review summarizes the effect of leukemia on semen parameters from adult patients and highlights feasible suggested mechanisms that may affect impairment of spermatogenesis in these patients. We suggest the possible involvement of leukemia in disturbing hormones involved in spermatogenesis, and the imbalance in testicular paracrine/autocrine factors involved in the formation of SSC niches that control their proliferation and differentiation. Understanding the mechanisms of leukemia in the impairment of spermatogenesis may lead to the development of novel therapeutic strategies mainly for prepubertal boys who do not yet produce sperm.

Prevalence of abnormal semen analysis and levels of adherence with fertility preservation in men undergoing therapy for newly diagnosed cancer: A retrospective study in 2906 patients

BACKGROUND

Sperm cryopreservation (freezing) should be offered to all men with cancer due to risk of infertility. However, many men with cancer already have impaired spermatogenesis prior to sperm cryopreservation. Furthermore, physical ill-health may hinder attendance of freeze visits. Investigating both the distribution of sperm functions and freeze attendance rates in men with newly diagnosed cancer, may identify patients benefiting from targeted reproductive fertility support.

METHODS

We performed a retrospective study of 2906 male patients undergoing sperm cryopreservation prior to cancer therapy at a single UK tertiary centre between 1989 and 2013; all patients were asked to attend three hospital semen collection visits prior to cancer therapy.

RESULTS

Fifteen per cent (433/2906) of men with newly diagnosed cancer had severely impaired semen quality (i.e., sperm total motile count, TMC < 1 million) during the first semen collection visit. However, patients with severely impaired semen quality had the poorest attendance of subsequent semen collection visits despite being requested to do so (non-attendance in TMC < 1 million: 43.4%; TMC < 1-30 million: 35.7%, P < 0.05 vs. <1 million; TMC > 30 million: 33.2%, P < 0.01 vs. <1 million).

CONCLUSIONS

This study expands understanding of the semen quality of men with newly diagnosed cancer, and their ability to adhere to fertility preservation recommendations. Our data suggest that patients with the poorest semen quality paradoxically suffer the poorest attendance rates of sperm cryopreservation appointments prior to commencing cancer therapy. We suggest that additional support may be of clinical benefit to men with newly diagnosed cancer and TMC < 1 million sperm.

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.

Semen quality before cryopreservation and after thawing in 543 patients with testicular cancer

OBJECTIVE

The main objective of this study was to assess semen characteristics of patients with testicular cancer before cryopreservation and after thawing, to evaluate the consequences of this technique on sperm quality in patients with testicular cancer.

METHODS

Five hundred eighty-nine samples from 543 patients with testicular cancer were cryopreserved between 1995 and 2015, one aliquot per patient was used for a thawing test to assess the impact of cryopreservation on sperm motility; semen analysis was performed before cryo preservation and after thawing, the result interpretation was carried out using the 2010 World Health Organization (WHO) Laboratory Manual, and consent forms were signed by the patients for freezing and when sperm was used for reproductive purposes.

RESULTS

Hypospermia was observed in 28.7% of samples, the median sperm concentration was 18 million/mL with 35% oligozoospermia; twenty-two patients (4.1%) had azoospermia and 12.7% had severe oligozoospermia, the median sperm count was 31.3 million and 261 semen samples (44.3%) were normal in all parameters according to the WHO; total motile sperm count before cryopreservation and after thawing was 12 (0-412.2) and 7 (0-303.9) million sperm, respectively (p < 0.00001, 95% CI 5.48-14.91), which represents a 32% reduction; concerning the utilization of cryopreserved semen samples, only twelve patients (2.2%) used their frozen sperm for reproductive purposes.

CONCLUSIONS

An impairment in semen quality was found in almost half of the samples from patients with testicular cancer, only few patients had azoospermia or severe oligozoospermia; sperm cryopreservation significantly reduces sperm motility and total motile sperm count and very few patients use their frozen sperm for reproductive purposes.

Sperm DNA fragmentation in cryopreserved samples from subjects with different cancers

Sperm cryopreservation is widely used by cancer patients undergoing chemo- or radiotherapy. Evidence suggests that IVF outcome with cryopreserved spermatozoa from cancer patients is less successful. To determine whether sperm DNA fragmentation (SDF) is involved in the lower fertilising ability of cryopreserved spermatozoa of cancer patients, SDF was evaluated in thawed spermatozoa from 78 men affected by different cancers and 53 men with non-cancer pathologies. SDF was assessed by the terminal deoxyribonucleotidyl transferase-mediated dUTP–digoxigenin nick end-labelling (TUNEL), propidium iodide (PI), flow cytometry procedure, which allows determination of two different cell populations (PIbrighter and PIdimmer) and thus to determine the percentage of DNA fragmented sperm in both. PIdimmer spermatozoa are totally unviable, whereas PIbrighter spermatozoa with SDF may be motile and morphologically normal, having higher biological relevance in the reproductive process. We found that the proportion of DNA fragmented PIbrighter cells was significantly higher in thawed spermatozoa from cancer than non-cancer patients. Moreover, a positive correlation was found between the degree of DNA fragmentation and sperm motility in the PIbrighter population of spermatozoa from cancer patients that wasn’t seen in non-cancer patients. The results of the present study suggest that higher SDF levels may contribute to the lower IVF success of cryopreserved spermatozoa from cancer patients and that evaluation of SDF could complement genetic counselling as part of the routine management of cancer patients who seek fertility preservation.

Predictors of sperm recovery after cryopreservation in testicular cancer

Our objective was to identify predictors of improved postthaw semen quality in men with testicular cancer banking sperm for fertility preservation. We reviewed 173 individual semen samples provided by 67 men with testicular germ cell tumor (TGCT) who cryopreserved sperm before gonadotoxic treatment between 1994 and 2010 at our tertiary university medical center. Our main outcomes measures were independent predictors for the greater postthaw total motile count (TMC) in men with TGCT. Men with NSGCT were more likely to be younger (P < 0.01) and had high cancer stage (II or III, P < 0.01) compared with men with seminoma. In our multiple regression model, NSGCT histology, use of density gradient purification, and fresh TMC > median fresh TMC each had increased odds of a postthaw TMC greater than median postthaw TMC. Interestingly, age, advanced cancer stage (II or III), rapid freezing protocol, and motility enhancer did not show increased odds of improved postthaw TMC in our models. In conclusion, men with TGCT or poor fresh TMC should consider preserving additional vials (at least 15 vials) before oncologic treatment. Density gradient purification should be routinely used to optimize postthaw TMC in men with TGCT. Larger, randomized studies evaluating cancer stage and various cryopreservation techniques are needed to assist in counseling men with TGCT regarding fertility preservation and optimizing cryosurvival.

Contemporary and future insights into fertility preservation in male cancer patients

In recent years, survival rates of cancer patients have increased, resulting in a shift of focus from quantity to quality of life. A key aspect of quality of life is fertility potential; patients suffering from iatrogenic infertility often become depressed. Since many cancer therapies—chemotherapy, radiotherapy and/or surgery—and even cancer itself have detrimental effects on the male reproductive system, it is important to preserve fertility before any treatment commences. Currently, the only reliable method of male fertility preservation is sperm banking. For patients who are unable to provide semen samples by the conventional method of masturbation, there are other techniques such as electroejaculation, microsurgical epididymal sperm aspiration and testicular sperm extraction that can be employed. Unfortunately, it is presently impossible to preserve the fertility potential of pre-pubertal patients. Due to the increasing numbers of adolescent cancer patients surviving treatment, extensive research is being conducted into several possible methods such as testicular tissue cryopreservation, xenografting, in vitro gamete maturation and even the creation of artificial gametes. However, in spite of its ease, safety, convenience and many accompanying benefits, sperm banking remains underutilized in cancer patients. There are several barriers involved such as the lack of information and the urgency to begin treatment, but various measures can be put in place to overcome these barriers so that sperm banking can be more widely utilized.

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.

[Influence of malignant tumors occurring in the reproductive age on spermiogenesis: studies on patients with testicular tumor and lymphoma]

INTRODUCTION

The application of chemo- and radiotherapy results in good survival prognosis for young men with malignant tumors, but long-term gonadoxic effect has to be considered. In addition, malignant disease itself has a negative impact on spermiogenesis.

AIM

The aim of the authors was to examine the spermiogenetic effect of the most common tumors occurring in the reproductive age in men: testicular cancer, Hodgkin disease and non-Hodgkin disease.

METHOD

Spermiogram of men with testicular cancer (N = 68), Hodgkin disease (N = 37) and non-Hodgkin disease (N = 14) who were referred for sperm cryopreservation were analysed in the Reproductive Andrology Laboratory of the authors.

RESULTS

Azoospermia was found in 11.8% of all patients (N = 119), while 58.8% of the patients had oligozoospermia even before the treatment. Sperm concentration of men with testicular cancer was significantly lower than those with lymphomas (32.8 M/mL vs. 24.9 M/mL, p = 0.03). There was no difference in sperm concentration between the Hodgkin and non-Hodgkin lymphoma groups.

CONCLUSIONS

Spermiogenetic defect is more pronounced in men with testicular cancer than those with lymphomas. Cryopreservation before treatment for fertility preservation should be offered for all reproductive aged men with malignant disease, especially for those with testicular cancer.

Impact of lymphoma treatments on spermatogenesis and sperm deoxyribonucleic acid: a multicenter prospective study from the CECOS network

OBJECTIVE

To determine consequences of lymphoma treatments on sperm characteristics and sperm DNA, and to evaluate predictors of sperm recovery.

DESIGN

Multicenter prospective longitudinal study of patients analyzed before treatment and after 3, 6, 12, and 24 months.

SETTING

University hospitals.

PATIENT(S)

Seventy-five Hodgkin lymphoma and non-Hodgkin lymphoma patients and a control group of 257 fertile men.

INTERVENTION(S)

Semen analyses, and sperm DNA and chromatin assessments.

MAIN OUTCOME MEASURE(S)

Comparisons of sperm characteristics before and after treatment.

RESULT(S)

Patients already had altered sperm characteristics before lymphoma treatment, with no identified risk factor. Sperm count, total sperm count, motility, and vitality decreased after treatment, with lowest values at 3 and 6 months. Twelve months after treatment, mean sperm count recovered to pretreatment values after doxorubicin, bleomycin, vinblastine, darcarbacine (ABVD) or ABVD+radiotherapy, but not after doxorubicin, cyclophosphamide, vincristine, prednisone (CHOP) or mechlorethamine, oncovin, procarbazine, prednisone (MOPP) chemotherapies. It was noteworthy that 7% of patients remained azoospermic at 24 months. After 24 months, Kaplan-Meier estimates showed that more than 90% of patients will recover normal sperm count after ABVD or ABVD+radiotherapy vs. 61% for CHOP chemotherapies. In multivariate analyses including diagnosis and treatment protocol, only pretreatment total sperm count was related to recovery. Compared with a control group, lymphoma patients had higher sperm chromatin alterations and DNA fragmentation before any treatment. After treatment, DNA fragmentation assessed by TUNEL assay and sperm chromatin structure assay decreased from 3 and 6 months, respectively, while remaining higher than in the control group during follow-up.

CONCLUSION(S)

Lymphoma patients had altered sperm DNA and chromatin before treatment. Lymphoma treatment had damaging effects on spermatogenesis. These data on both the recovery period according to treatment modalities and the pre- and post-treatment chromatin status of sperm are useful tools for counseling patients wishing to conceive.

Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion

Patients preparing to undergo gonadotoxic medical therapy or radiation therapy or gonadectomy should be provided with prompt counseling regarding available options for fertility preservation. Fertility preservation can best be provided by comprehensive programs designed and equipped to confront the unique challenges facing these patients.

Use of an oncology sperm bank: a Canadian experience

BACKGROUND: We performed a retrospective chart review in 2006 to review oncology patients' use of banked semen samples in fertility treatments at a tertiary care centre. METHODS: From 2002 to 2005, 367 oncology patients banked semen. During the same period, 31 patients used banked samples in 48 treatment cycles. Samples were used for intrauterine insemination (IUI) in 28 cycles and for in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) in 20 cycles. RESULTS: Pregnancy rates per cycle were 21% for IUI and 50% for IVF with or without ICSI. Overall, 16 of the 31 couples achieved a pregnancy with assisted reproductive technologies (52%). CONCLUSION: This data indicates high pregnancy success rates with the use of banked semen samples from men with cancer.

Preservation of sperm of cancer patients: extent of use and pregnancy outcome in a tertiary infertility center

Sperm cryopreservation is the best modality to ensure future fertility for males diagnosed with cancer. The extent to which cryopreserved sperm is actually used for impregnation, the fertility treatment options that are available and the success rates of these treatments have not been investigated in depth. The medical records of 682 patients who cryopreserved sperm cells due to cancer treatment were analyzed. Seventy of these patients withdrew their frozen sperm for fertility treatments over a 20-year period (most within the first 4 years after cryopreservation). Sperm quality of different malignancies and outcomes of assisted reproduction treatment (ART) for pregnancy achievement in relation to the type of treatment and the type of malignancy were evaluated. The results showed that the rate of using cryo-thawed sperm from cancer patients for fertility treatments in our unit was 10.3%. Sperm quality indices differed between different types of malignancies, with the poorest quality measured in testicular cancer. Conception was achieved in 46 of the 184 ART cycles (25%), and resulted in 36 deliveries. The use of intracytoplasmic sperm injection (ICSI) methodology yielded a significantly higher pregnancy rate (37.4%) than intrauterine insemination (IUI; 11.5%) and was similar to other groups of infertile couples using these modalities. In vitro fertilization (IVF) failed to produce pregnancies. In conclusion, the rate of use of cryopresseved sperm in cancer patients is relatively low (10.3%). Achievement of pregnancies by ICSI presents the best option but when there are enough stored sperm samples and adequate quality, IUI can be employed. Cryopreservation is nevertheless the best option to preserve future fertility potential and hope for cancer patients.

Raw and test-thaw semen parameters after cryopreservation among men with newly diagnosed cancer

OBJECTIVE

To characterize sperm parameters from thawed semen samples of men with different cancers who cryopreserved semen before oncologic therapy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical center.

PATIENT(S)

1,010 semen samples collected between 1994 to 2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mean total motile count (TMC), change in percentage motility and percentage survival (100 * [postthaw % motility/raw % motility]) for each cancer compared with data from samples of men without cancer (the "procreative management" group), and proportion of postthaw samples with TMC >5 × 10(6).

RESULT(S)

The procreative management group had the best raw and postthaw semen quality. The best raw and postthaw semen quality for cancer patients occurred in those with prostate cancer (TMC of 155.1 and 53.2 × 10(6), respectively) and the worst in those with leukemias. Lymphoid leukemias demonstrated the worst raw TMC (26.8 × 10(6)), but myeloid leukemias displayed the worst postthaw TMC (6.9 × 10(6)). The testicular cancer group was the only group with a statistically significantly lower chance of having TMC >5 × 10(6).

CONCLUSION(S)

Men with testicular cancer were most commonly referred for sperm cryopreservation and were the only group that was statistically significantly less likely to have TMC >5 × 10(6) on postthaw semen analysis. The most severe reduction in TMC was seen in the myeloid leukemia group, suggesting that these patients along with men with testis cancer and those with lymphoid leukemia should be counseled to provide increased numbers of specimens for fertility preservation.

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.

Recovery, Preparation, Storage and Utilization of Spermatozoa for Fertility Preservation in Cancer Patients and Sub-Fertile Men

Sperm cryopreservation is an important part of an infertility program for patients undergoing infertility treatments, fertility assurance for vasectomy cases, and for fertility preservation due to cancer or other medical conditions. With recent developments in reproductive technology, even men with severely impaired sperm parameters can benefit from cryopreservation as procedures such as intra-cytoplasmic sperm injection (ICSI) require only a few sperm to achieve fertilization and pregnancy. The increasing success of cancer treatment and concerted efforts to ensure quality of life after successful treatment have placed great emphasis on the need to preserve the reproductive capability of young men. It is a highly effective method of protecting male fertility potential, and involves collection, freezing, and long-term storage of sperm. Based on the etiological condition of the patients, sperm can be collected by ejaculation or by surgical retrieval from epididymis or testes. The option to bank sperm should be offered systematically to all patients who may benefit. However, this is not a standard of practice yet; it may be overlooked due to lack of physician awareness regarding the need for fertility preservation and the effectiveness of this option, and/or overestimating the limitations of poor baseline sperm quality leading physician to view cryopreservation as futile. Failure to offer cryopreservation ignores the only possible reproductive option available to certain patients.

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.

Semen quality in men with disseminated testicular cancer: relation with human chorionic gonadotropin beta-subunit and pituitary gonadal hormones

OBJECTIVE

To compare the semen quality and hormonal status between patients with testicular cancer and normal versus increased serum levels of beta-hCG.

DESIGN

Retrospective study.

SETTING

Academic research environment.

PATIENT(S)

All 203 patients with testicular cancer who required chemotherapy in the period 1995-2003 were included.

INTERVENTION(S)

In 107 patients semen samples were stored by cryopreservation; 62 patients could be analyzed because both semen was stored and hormones were determined before starting chemotherapy (median age 25 years, range 17-49 years).

MAIN OUTCOME MEASURE(S)

Total motile sperm count, T, E(2), LH, FSH, and PRL.

RESULT(S)

Total motile sperm count was decreased in patients with increased beta-hCG (median 11.9 x 10(6)) compared with patients with normal beta-hCG (median 21.5 x 10(6)). Testosterone, E(2), and PRL were significantly higher in patients with increased beta-hCG levels, whereas LH and FSH were lower. Semen quality was significantly and negatively correlated with beta-hCG, E(2), and PRL.

CONCLUSION(S)

Patients with increased beta-hCG had an inferior spermatogenesis compared with patients with normal beta-hCG. Increased beta-hCG appears to be associated with impaired spermatogenesis and increased levels of E(2) and PRL.

Pediatric fertility preservation: is it time to offer testicular tissue cryopreservation?

As the effectiveness of cancer treatments has improved, children diagnosed with cancer can enjoy a longer life free of the disease. However, chemotherapeutic regimens alone or in combination with radiation therapy frequently result in azoospermia or infertility. This paper reviews currently and potentially available methods to maintain fertility in boys undergoing chemotherapy or radiation therapy. Whenever possible, chemotherapeutic agents that are less likely to cause azoospermia, should be considered. Hormonal suppression applied prior to and during chemotherapy may protect future male fertility. Cryopreservation of sperm enables men to reproduce in the future. New techniques, such as in vitro fertilization with intra-cytoplasmic sperm injection offer a more promising future for male cancer sufferers. These techniques however, are not applicable to pre-puberty cancer patients. The use of spermatogonial and embryonic stem cells open new possibilities for boys diagnosed with cancer.

Sperm banking: use and outcomes in patients treated for testicular cancer

OBJECTIVE

To identify the frequency that sperm banking was used by men being treated for testicular cancer at our institution, and to characterize the differences between men choosing to bank sperm or not, and outcomes in terms of after-treatment pregnancies.

PATIENTS AND METHODS

A questionnaire addressing sperm banking and fertility was administered to men treated for testicular cancer at our institution between 1994 and 2004; the results were evaluated statistically.

RESULTS

Overall, 31 of 129 (24%) respondents had banked sperm. Of these, two had used their banked sperm to father a child, and 12 had had children naturally. Men who banked sperm were a mean of 10.3 years younger (P < 0.001) and less likely to have children at the time of diagnosis (P < 0.025) than men choosing not to bank sperm. The cost of banking sperm was reported to include a mean fee of US dollars 358 (median 300, range 0-1000), and a mean annual maintenance fee of US dollars 243.86 (median 300, range 0-1200).

CONCLUSIONS

Only a minority of men in this study chose to bank sperm (24%). Among those who did, the use of banked sperm was low (<10%), and many men could have children without using banked sperm. Given the relatively high costs of sperm banking and the low rate of sample use, patients should be counselled on the costs and benefits of sperm banking before treatment for testicular cancer.

Gonad evaluation in male systemic lupus erythematosus

OBJECTIVE

To assess gonad function in male patients with systemic lupus erythematosus (SLE).

METHODS

Thirty-five consecutive male patients with SLE according to the criteria of the American College of Rheumatology were prospectively evaluated for demographic and clinical features as well as previous and current treatment. Patients underwent urologic evaluation and testicular Doppler ultrasound. We obtained a hormone profile and performed a semen analysis including morphology and testing for the presence of antisperm antibodies. Patients were compared with 35 age-matched healthy controls.

RESULTS

Compared with controls, SLE patients had lower median testicular volumes in both testes, a lower median total sperm count, and a lower median total motile sperm count. The mean sperm volume and percentage of normally formed sperm were lower in SLE patients than in controls. Since all SLE patients had semen alterations, they were further subdivided into 2 groups according to the severity of these abnormalities (group 1, with teratozoospermia [n = 18], and group 2, with azoospermia or teratozoospermia in combination with oligozoospermia and/or asthenozoospermia [n = 17]). The frequency of treatment with intravenous cyclophosphamide (IV CYC) after the first ejaculation was higher in group 2 than in group 1. The median testicular volumes measured by ultrasound in both testicles were lower in group 2 than in group 1. Follicle-stimulating hormone levels were higher in group 2 than in group 1. The overall frequency of antisperm antibodies in SLE patients was 40%. The apparent higher frequency of antisperm antibodies in group 1 than in group 2 did not reach significance.

CONCLUSION

SLE patients have a high frequency of sperm abnormalities associated with reduced testicular volume. Postpubertal IV CYC treatment was the major factor in potential permanent damage to the testes.

Gonadal damage and options for fertility preservation in female and male cancer survivors

It is estimated that in 2010, 1 in every 250 adults will be a childhood cancer survivor. Today, oncological surgery, radiotherapy and chemotherapy achieve relatively high rates of remission and long-term survival, yet are often detrimental to fertility. Quality of life is increasingly important to long-term survivors of cancer, and one of the major quality-of-life issues is the ability to produce and raise normal children. Developments in the near future in the emerging field of fertility preservation in cancer survivors promise to be very exciting. This article reviews the published literature, discusses the effects of cancer treatment on fertility and presents the options available today thanks to advances in assisted-reproduction technology for maintaining fertility in male and female patients undergoing this type of treatment. The various diagnostic methods of assessing the fertility potential and the efficacy of in vitro fertilization (IVF) after cancer treatment are also presented.

Facilitators and obstacles to sperm banking in young men receiving gonadotoxic chemotherapy for cancer: the perspective of survivors and health care professionals

BACKGROUND

Testicular cancer and Hodgkin's disease are among the most common malignancies to affect young men of reproductive age. Although both are associated with high rates of infertility, sperm banking (SB) remains underutilized by both diagnostic groups. Reasons for this remain elusive.

METHODS

This study used a qualitative design. In-depth interviews were conducted with 20 cancer survivors and 18 health care professionals (HCPs) to examine their perspectives on factors that facilitate or hinder SB. Interview data were analysed using a mixed approach and a three-step process of data reduction, data display and conclusion drawing and verification.

RESULTS

Eight factors were identified as having an impact on SB, and findings suggest that effective promotion of SB involves adequate communication around the severity and personal risk for infertility, assessing the importance of patients place on having children, emphasizing the benefits of SB and addressing possible obstacles such as cost, misperceptions or cultural and other factors. In addition, the communicator should be perceived as appealing.

CONCLUSIONS

These results are conceptually consistent with both the Health Belief Model and the Elaboration Likelihood Model of health promotion and are useful in informing HCPs on how to better promote SB.

Long-term effects of cryopreservation on human spermatozoa

We evaluated the long-term effects of cryopreservation on spermatozoa of men with testicular cancer, lymphoma, and benign conditions. No statistically significant decrease in semen parameters was noted. Duration of follow-up was up to 5 years and mean follow-up was 2 years.

In vitro fertilization-intracytoplasmic sperm injection success rates with cryopreserved sperm from patients with malignant disease

OBJECTIVE

To describe the success rate of intracytoplasmic sperm injection (ICSI) using thawed cryopreserved sperm in male cancer patients.

DESIGN

Retrospective consecutive study.

SETTING

IVF unit in a tertiary university hospital.

PATIENT(S)

Twenty-one couples treated by ICSI using the frozen-thawed sperm of husbands treated for cancer.

INTERVENTION(S)

Follow-up of all treatments by ICSI.

MAIN OUTCOME MEASURE(S)

Pregnancy rate, sperm count, and fertilization rate.

RESULT(S)

Male patients being treated for cancer froze between one and 29 sperm samples. Post-thaw sperm count ranged from 1 x 10(5) to 106 x 10(6). The mean fertilization rate by ICSI was 60% (range, 33%-100%), and the pregnancy rate was 42%. Twenty-six pregnancies were obtained resulting in 23 children (13 singleton and 10 twins) and eight spontaneous abortions (31%). Delivery was obtained in 12 of the 21 treated couples (57%). The lowest total motile sperm count that resulted in a pregnancy was 1 x 10(5).

CONCLUSION(S)

Male cancer patients should be encouraged to freeze numerous sperm samples even when sperm count and motility are poor. In these cases, ICSI is a powerful technique compared with intrauterine injection since thawed sperm samples with poor parameters can produce relatively high fertilization rates resulting in normal pregnancies and deliveries. The possibility to repeat treatments even in the face of a limited number of sperm samples appears to be of importance.

Assisted reproduction in male cancer survivors: fertility treatment and outcome in 67 couples

BACKGROUND

Many male cancer survivors experience fertility problems due to antineoplastic treatment. We report the fertility outcome in 67 couples referred to assisted reproduction treatment (ART) because of male factor infertility due to cancer.

METHODS

This was a retrospective study assessing the following parameters: diagnosis, cancer treatment, type of fertility treatment and type of sperm used, number of pregnancies and pregnancy outcome.

RESULTS

Testicular cancer and lymphomas were the most prevalent diagnoses. Adjuvant treatment with chemo- and/or radiation therapy had been given to 90% of the men. Semen was cryopreserved in 82% of the men prior to treatment. Following antineoplastic treatment, 43% of the men had motile spermatozoa in the ejaculate, but 57% were azoospermic. A total of 151 ART cycles were performed [55 intra-uterine insemination (IUI), 82 ICSI and 14 ICSI-frozen embryo replacement (FER)]. The clinical pregnancy rate per cycle was 14.8% after IUI, 38.6% after ICSI and 25% after ICSI-FER. The corresponding delivery rates were 11.1, 30.5 and 21%. Cryopreserved semen was used in 58% of the pregnancies. The delivery rate per cycle was similar after use of fresh or cryopreserved spermatozoa.

CONCLUSIONS

Male cancer survivors have a good chance of fathering a child by using either fresh ejaculated sperm or cryopreserved sperm.

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

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

Testicular function following chemo-radiotherapy

Improvements in cancer survival raise infertility issues in young patients suffering from malignancies. The aim of the study is to review current knowledge on the effect of chemotherapy (CT) and radiotherapy (RT) for testis and hematological neoplasms on testicular function. Cisplatin-based regimens for testis neoplasm induce temporary azoospermia; permanent damage can occur with high doses (400-600 mg/m(2)). Alkylating agents are very effective for hematological neoplasm therapy but extremely dangerous to germinal epithelium. Damage can be irreversible. Spermatozoa cannot tolerate irradiation doses higher than 6 Gy. Leydig cells are damaged by doses higher than 15 Gy. A-Spermatogonia have been shown to survive after CT and RT and their recovery for post-treatment graft has been recently developed in animal models. Infertility counselling before treatment in young oncological patients is mandatory. Cryopreservation is the best option for fertility protection.

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.