Onco Fertility for Physicians
Fertility & Cancer: Oncofertility for Physicians
Both cancer and cancer treatments can adversely affect a man’s ability to father children. Cancer can impair spermatogenesis by hormonal derangements as well as by direct involvement of testicular tissue and the reproductive tract. Additionally, erectile and ejaculatory dysfunction may result from the debilitating physical and emotional impacts of the disease and as side effects of various medical and surgical therapies.
Effect of Cancer Treatment on Fertility
Chemotherapy and radiation therapy cure cancer by destroying rapidly diving cells. Unfortunately, from a male fertility perspective, cells of the seminiferous epithelium undergo continuous and rapid cell division and are thus vulnerable and killed when exposed to anti-neoplastic therapies.
Despite the use of gonadal shielding with radiation therapy and efforts to tailor chemotherapeutic regimens to be less gonadotoxic, nearly all cancer treatments — while life-saving — negatively impact male infertility. Statistically, most men of reproductive age with cancer will survive, and the ability to father children following treatment is a very important quality-of-life concern for them.
Even though many men will recover spermatogenesis following cancer treatment, a significant number will not. It is very difficult to predict who will or won’t recover spermatogenesis after treatment due to a number of variables including type of cancer, extent of disease, doses of either chemotherapy and/or radiation, and the unpredictable individual susceptibility to the various treatments. Additionally, when spermatogenesis returns, it frequently does not rebound to the same level prior to treatment, and sperm quality after treatment is often a concern.
Sperm Cryopreservation Prior to Cancer Treatment
Sperm cryopreservation prior to cancer treatment remains the mainstay of ensuring that a man may father a child in the future with his own sperm. Given the multiple uncertainties of cancer therapies as well as the emotionally-charged and time-sensitive nature of starting treatment, it is critical to be able to provide for these men and their families an easy, efficient, well-coordinated and cost-effective way of offering sperm cryopreservation prior to treatment.
The primary method of performing sperm cryopreservation is to ask a man to collect a semen sample and freezing motile sperm, if present. In the situation where either no viable sperm are present in the semen sample or if the man is unable to collect a semen sample, then techniques of surgical sperm retrieval need to be offered. Surgical sperm retrieval requires a urologist who is knowledgeable in these techniques in combination with an andrology laboratory that is willing and available to work with the patient and the urologist to coordinate this important service.
Fertility Preservation – Where Does It Fit?
Once a man is diagnosed with cancer, a treatment plan must be developed. It is critical for the doctor and/or the patient to ask about and discuss whether or not treatment will put future fertility at risk. If the proposed treatment will not risk a man’s future fertility, then he should proceed with treatment. If the proposed treatment will risk future fertility, then the doctor should discuss the impact of both cancer and treatment on reproductive health. If the man is not interested in fertility preservation, then he should proceed with treatment. If the man is interested in fertility preservation, then he should be referred to a reproductive specialist. A semen sample should then be obtained. If live sperm are found, then they may be cryopreserved. If live sperm are not present in the semen sample, or if the man is unable to produce a semen sample, then other fertility preservation options such as surgical sperm retrieval should be discussed.
Talking to Your Patients about Cancer and Fertility
You may not be comfortable speaking with your patients about the risk of infertility related to their cancer or planned cancer treatment. These key points can help start the conversation:
- Cancer and cancer treatment may affect your fertility.
- Based on your treatment plan, your risk of infertility is [high, moderate, low].
- Have you ever thought about having a child/more children? Although it may not be on your mind now, many patients find themselves wishing they had thought about this when they had the chance.
- You have options to try to preserve your fertility before you begin cancer treatment.
- Cancer, cancer treatment, or fertility preservation procedures usually will not harm your future children. (Although you might pass on the gene for some cancers, it may be possible to test for those).
- Fertility preservation procedures do not appear to increase the risk of cancer recurrence.
- I can refer you to a fertility preservation specialist if you would like to discuss your options further.
- Remember that there are other ways to build a family after cancer if we are unable to preserve your fertility now. Talking with a specialist can help you explore other options that might be right for you.
Options for Fertility Preservation
There are two standard options for men diagnosed with cancer who wish to preserve their fertility:
- Sperm banking prior to cancer therapy
- Radiation shielding of the testes during radiation therapy
The American Society of Clinical Oncology and the American Society for Reproductive Medicine recommend that, when possible, at-risk patients are referred to a fertility preservation specialist prior to starting cancer treatment.
Men who are interested in fertility preservation prior to starting cancer therapy will provide a semen sample for analysis.
The following figure illustrates fertility preservation options based on the results of the semen sample analysis.
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