Oncology Journal of India

EDITORIAL
Year
: 2017  |  Volume : 1  |  Issue : 2  |  Page : 23--24

Fertility issue and sperm banking among testicular cancer survivors


Tapan Kumar Sahoo 
 Department of Radiotherapy, HCG Panda Cancer Hospital, Cuttack, Odisha, India

Correspondence Address:
Dr. Tapan Kumar Sahoo
Department of Radiotherapy, HCG Panda Cancer Hospital, Cuttack, Odisha
India




How to cite this article:
Sahoo TK. Fertility issue and sperm banking among testicular cancer survivors.Oncol J India 2017;1:23-24


How to cite this URL:
Sahoo TK. Fertility issue and sperm banking among testicular cancer survivors. Oncol J India [serial online] 2017 [cited 2018 Sep 18 ];1:23-24
Available from: http://www.ojionline.org/text.asp?2017/1/2/23/223683


Full Text



Due to advances in the treatment of cancers, the long-term survival has become possible in cancer survivors. However, these patients suffer from the adverse effects due to the past treatment. Both chemotherapy and radiotherapy may inflict gonadal injury, and infertility is an important side effect in cancer survivors affecting the psychological aspects of life. It is usually difficult to predict the cancer survivors to be the father of a child after the completion of treatment in comparison to noncancerous general population. Therefore, the issue in treating the cancer patients is not only the treatment, but also the fertility preservation.

Testicular cancer (TC) is one of the curable cancers, with more than 95% 10-year survival rates affecting men of reproductive age group. It is the most common malignancy among male in the age group of 20–40 years. High inguinal orchidectomy, radiotherapy, platinum-based chemotherapy regimen, and retroperitoneal lymph node dissection (RPLND) are the important treatment modalities for the TC and these treatment modalities may compromise fertility, either temporarily or permanently.[1] Fertility is an important concern for cancer survivors who have not yet begot children.

RPLND may cause injury to the retroperitoneal sympathetic nerve complex that enters the superior hypogastric plexus leading to ejaculatory dysfunction and infertility, and bilateral RPLND without a nerve-sparing technique may cause impairment of fertility in >90% of patients.[2] In retrograde ejaculation, the person is not sterile, and sperms are still there, and needs to retrieve the semen from the bladder for using in fertility procedures.

Gonadotoxic agents may directly damage proliferating cells, particularly early differentiating sperm cells, causing oligospermia or azoospermia. Chemotherapeutic drugs may injure mature germ cells by entering through the sertoli cell barriers. In 40% of patients receiving chemotherapy, sperm counts may reduce permanently impairing future fertility.[3] Cisplatin, etoposide, and bleomycin are the primary chemotherapeutic agents used in TC treatment and all of these possess the risk of gonadal dysfunction. The cumulative dose of cisplatin of <400 mg/m 2 is the determinant factor for the reversibility of impaired spermatogenesis. The sperm count may increase after the completion of chemotherapy and it depends on the initial sperm quality and the amount of chemotherapy received.

Radiation-induced fertility damage is mostly caused by scattered radiation to the neighboring tissues. Radiotherapy directly induces DNA damage and the germinal epithelia of the testis are more sensitive to it.[4] 0.1–1.2 Gy radiotherapy dose may impair spermatogenesis, a dose above 4 Gy causes permanent azoospermia, and doses of 16–18 Gy cause Sertoli cell-only syndrome.[2] However, the radiation dose at the level of testicles is less and the dose depends on the extent of external beam radiation treatment field into the pelvis.

Recovery of spermatogenesis after TC treatment is not clear. With regard to long-term recovery from spermatogenesis, surgery (RPLND) is less harmful in comparison to chemotherapy and radiotherapy. Recovery from retrograde ejaculation is improved in nerve-sparing RPLND. Persons may suffer from azoospermia following radiotherapy. Partial recovery in spermatogenesis following completion of chemotherapy may occur within 2 years. Few patients may achieve biological conception but with a difficulty in comparison to the normal population.

There may be co-existence of TC patients with a low sperm concentration and a high rate of abnormal sperm morphology. Therefore, fertility should be determined on the basis of both pre- and posttreatment evaluations. The impact of quality of life on fertility is an important issue and depends on many factors such as social and emotional functions, treatment and financial satisfaction, sexual dysfunction including erectile dysfunction, and body image problems.[5]

Sperm banking is a simple, accessible, and affordable way to provide an opportunity to TC survivors for paternity following treatment. However, the sperm preservation rates in TC are low and the usage rates are even lower (<10%) owing to various factors such as lack of awareness among the medical team and patients, the short time gap between the diagnosis and treatment, poor semen quality with immotile sperm, failure in ejaculation due to high anxiety and weakness, disease stage, prior children, and decision of patients to stop having more children, and institutional practice.[1],[2] In addition, the availability of sperm banking at the local place and the price of preserving sperm is an important issue. Semen cryopreservation should be done prior to treatment due to poor DNA integrity and quality of sperm after treatment of TC.[6]

Males reaching puberty and containing healthy viable sperm can bank sperm. Sperms can be collected by normal masturbation, or electroejaculation or penile vibration under anesthesia in difficulty cases. The sample containing live sperm cells can be frozen and stored for at least 20–30 years without further damage. Intrauterine insemination and/or in vitro fertilization with intracytoplasmic sperm injection (ICSI) should be the procedures to use cryopreserved sperm. Problems of low sperm number and poor motility in the use of intrauterine insemination may be resolved by the use of ICSI.[1]

TC survivors have a common concern about the risk of birth defects to their offspring after exposure to cytotoxic drugs or radiotherapy and however, data are lacking in this regard. After completion of therapy, men should wait for 12–24 months to pursue fertility treatment.[1]

In summary, all the treatment modalities for TC patients have a negative effect on spermatogenesis and sperm preservation should be considered before starting the treatment. Availability and awareness on sperm banking is necessary to both the medical team and TC survivors for the possible future fertility. Few queries should be well explained to the patients with TC such as the curability of TC, the consequence of the different treatment modalities on fertility, recovery of the fertility after completion of treatment, and the advantage of sperm banking with its success for future fertility.

References

1Ping P, Gu BH, Li P, Huang YR, Li Z. Fertility outcome of patients with testicular tumor: Before and after treatment. Asian J Androl 2014;16:107-11.
2Hamano I, Hatakeyama S, Ohyama C. Fertility preservation of patients with testicular cancer. Reprod Med Biol 2017;16:240-51.
3Sonnenburg DW, Brames MJ, Case-Eads S, Einhorn LH. Utilization of sperm banking and barriers to its use in testicular cancer patients. Support Care Cancer 2015;23:2763-8.
4O'Flaherty CM, Chan PT, Hales BF, Robaire B. Sperm chromatin structure components are differentially repaired in cancer survivors. J Androl 2012;33:629-36.
5Stoehr B, Schachtner L, Pichler R, Holzner B, Giesinger J, Oberguggenberger A, et al. Influence of achieved paternity on quality of life in testicular cancer survivors. BJU Int 2013;111:E207-12.
6Fraietta R, Spaine DM, Bertolla RP, Ortiz V, Cedenho AP. Individual and seminal characteristics of patients with testicular germ cell tumors. Fertil Steril 2010;94:2107-12.