Correspondence *Sol and Margaret Berger Department of Urology, Phillips Ambulatory Care Center, Beth Israel Medical Center, Suite 3A, 10 Union Square East, New York, NY 10003, USA

Email hnagler@bethisraelny.org

Original article

Neal MS et al. (2007) Effectiveness of sperm banking in adolescents and young adults with cancer. Cancer 110: 1125–1129   PubMed

Synopsis

Background

The survival rate of adolescent and young adult males with cancer is high, but cancer treatment can result in impaired fertility. Cryopreservation of semen before treatment is an option for maintaining fertility.

Objective

The objective of this study was to assess the efficacy and utilization of sperm cryopreservation for maintaining the fertility of adolescents and young adults with cancer.

Design and intervention

This study included males aged 30 years with cancer who had banked sperm between 1995 and 2005. Patients were divided into two groups: a pediatric group (patients aged 18 years) and an adult group (patients aged 18–30 years). Patients' records were reviewed for fertility, andrology and clinical features of disease such as age at diagnosis, type of cancer, treatment received, and outcome. Sperm analysis was performed according to the WHO guidelines before cryopreservation of semen samples. A subgroup analysis was performed on patients who used their samples to assist in conception, either by intrauterine insemination (IUI) or by in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI).

Outcome measures

Outcome measures for sperm analysis included viscosity, volume, pH, sperm concentration, morphology, motility and viability; the sample was considered to be normal if it had over three benchmark values for motility, strict morphology and concentration. Outcome measures for the subgroup analysis included fertilization success, embryo development and quality, number of embryos transferred, and implantation and pregnancy rates.

Results

Out of 821 male patients aged 14–30 years who were newly diagnosed with cancer at the study centers between 1995 and 2005, 146 (17.8%) banked their sperm (34 and 112 patients in the pediatric and adult groups, respectively). The most common cancers were Hodgkin lymphoma (37.5%) in the pediatric group and testicular cancer (43.9%) in the adult group. In total, sperm samples were considered to be normal in 21.1% of patients; 9.4% and 25.6% of pediatric and adult patients had normal sperm samples, respectively. Reduced motility and strict morphology were the most common reasons for abnormal samples. Of the 146 samples banked, 103 are still in cryopreservation, 22 were destroyed because of patient's wishes or patient death, and 21 were used in attempted conception. Eleven patients used their samples for IUI, and four patients' partners had a successful pregnancy. Ten patients used their samples for IVF plus ICSI: the mean fertilization rate was 72.5%, the mean cumulative embryo scores at 48 h, 72 h and after transfer were 11.6, 24.9 and 28.1, respectively, the mean number of frozen embryos was 1.8, the mean implantation rate was 60.4%, the mean pregnancy rate was 70.0% and the mean clinical pregnancy rate was 50.0%.

Conclusions

Sperm banking is an effective option for preserving fertility in adolescents and young adults with cancer who are about to undergo gonadotoxic treatment; however, the use of this facility is low.

Commentary

Adolescents and young adult males with cancer can experience infertility from the disease itself as well as its treatment. Chemotherapeutic drugs and radiation can affect sperm production by damaging the germinal epithelium, and surgical intervention can interfere with the delivery of sperm by causing obstruction or disrupting emission or ejaculation. As observed in this study, different cancers are associated with varying degrees of seminal abnormalities. Even patients with bilateral testicular cancers can have pretreatment semen parameters that are compatible with fertility.¹

Cryopreservation of sperm has been used for more than 50 years and is a well-established and readily available means of preserving or extending fertility. Oncologists are almost universally aware of sperm banking and Assisted Reproductive Technology. Published clinical guidelines address fertility prior to chemotherapy,² but relatively few patients bank sperm prior to initiating treatment. Edge et al.³ found that only 24% of male cancer patients aged 14–40 years banked sperm. This current study demonstrates a similarly low rate. So why do so few patients choose to preserve sperm when so many will become infertile and so few have children at the time of diagnosis? Though no causal relationship can be established in this retrospective article, research has demonstrated that the most common reason patients fail to bank sperm is that health care workers fail to offer the service: Edge et al.³ found that only 51% of patients were offered cryopreservation.

Most patients with whom fertility is discussed will choose to preserve their sperm.⁴ At the time of diagnosis, an adolescent patient cannot be expected to initiate this sensitive, embarrassing and, perhaps, abstract discussion. Patients are more concerned with fertility 2 years after treatment than they are before treatment is initiated.³ Reducing patient anxiety when discussing fertility, increasing patient understanding of sperm banking, and increasing patient awareness of the impact of treatment on fertility have all been shown to improve the likelihood of banking sperm;³ therefore, doctors and nurses should engage young patients in thoughtful discussions about fertility. Studies have demonstrated that sperm banking can be successfully achieved in patients as young as 15 years old. Even when ejaculates cannot be submitted, sperm might be obtained by electroejaculation or testicular sperm extraction. Given these data, physicians should initiate conversations with patients and their guardians.⁵

Hopefully, a patient will experience recovery of spermatogenesis. If not, a patient might eventually be faced with the decision of how to optimally utilize his cryopreserved sperm. Historically, IUI has been employed when cryopreserved sperm are available, as this procedure is less costly than IVF;⁶ however, one has to question whether cost should be of paramount importance. The authors observed a 36% pregnancy rate with IUI, while IVF patients had a 70% conception rate and a 50% clinical pregnancy rate. For patients who have no sperm in their ejaculates and who have only a finite number of cryopreserved sperm, proceeding directly to IVF might be more appropriate than attempting IUI.

We as professionals have an obligation to educate our newly diagnosed cancer patients about the effects of cancer and its treatment on fertility potential. We need to be certain that patients understand the options available to them to attempt to preserve their fertility. All patients should be offered cryopreservation of sperm prior to embarking on therapies known to adversely affect fertility.

Acknowledgments

The synopsis was written by Rachel Murphy, Associate Editor, Nature Clinical Practice.

References

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Subject areas under which this article appears: Male factor infertility