Sperm banking: use and outcomes in patients treated for testicular cancer
Christopher R. Girasole, Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.e-mail: email@example.com
Authors from the USA present a study aimed at identifying the frequency with which sperm banking was used in patients being treated for testicular cancer. They found that only a minority of their patients chose to bank sperm, and among those who did, the use was low.
Advanced penile cancer requires extensive ablative surgery with resultant anatomical defects that can result in severe loss of quality of life. Authors from the UK describe their experience with the vertical rectus abdominis musculocutaneous flap in such patients, finding it to be useful. They stressed that a multidisciplinary approach involving the urological reconstructive surgeon and the plastic surgeon is essential.
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.
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 $358 (median 300, range 0–1000), and a mean annual maintenance fee of $243.86 (median 300, range 0–1200).
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.
retroperitoneal lymph node dissection.
Many men with testicular cancer have impaired gonadal function before treatment ; often, semen analyses will improve after orchidectomy. However, most patients are offered adjuvant therapy with external beam radiotherapy, cytotoxic chemotherapy, or retroperitoneal lymph node dissection (RPLND), any of which can further impair fertility. Most men with testicular cancer are cured, with survival rates of > 90% due to the success of multimodal therapy . As testicular cancer is primarily a disease of young men, most of whom will survive, it seems crucial to preserve the ability to father children after cure. Revolutionary techniques such as in vitro fertilization and intracytoplasmic sperm injection make pregnancy possible with even the lowest quality of sperm. These factors probably contribute to the current practice by most urologists, radiation oncologists and medical oncologists to offer sperm banking before therapy for testicular cancer.
While offering sperm banking has become common among physicians caring for men with testicular cancer, there are few published data about the frequency and/or success of its use. To study this important issue we designed a questionnaire which was distributed to men treated for testicular cancer at our institution, and that addressed issues of fertility before and after treatment, frequency of sperm banking, use of cryopreserved sperm, and the associated costs.
PATIENTS AND METHODS
A questionnaire was administered to 330 men who were treated for testicular cancer at Vanderbilt University Medical Center from 1994 to 2004. The questionnaire addressed: the cancer treatment(s) received, fertility status of the patient (before and after treatment), marital status at the time of treatment, use of cryopreserved sperm, the decision to bank sperm or not, costs associated with sperm banking, and whether or not the patient recalled being offered sperm banking. Patient responses were collected and analysed. Chi-square and Fisher’s test were used for statistical analysis.
The questionnaire was completed by 129 of 330 men (39%); their mean age at diagnosis was 34.1 years. The mean age of respondents who banked sperm was 26.2 years, vs 36.5 years for those who did not, a difference of 10.3 years (95% CI 5.6–15.0, P < 0.001). There was no measured difference in the groups based on race. Men banking sperm were more likely to be single (P < 0.02). The rates of orchidectomy, RPLND, radiation, or chemotherapy were not significantly different between the groups. The respondents’ characteristics are summarized in Table 1.
Table 1. The patients’ characteristics
|Mean (range)age, years|| 34.1 (14–76)|| 26.2(18–43)|| 36.5(14–76)|
| Caucasian||125 (96.9)||29 (93.5)||96 (98.0)|
| African-American|| 3 (2.3)|| 2 (6.5)|| 1 (1.0)|
| Asian|| 1 (0.8)|| 0|| 1 (1.0)|
| Single|| 25 (13.4)||11 (35.5)||14 (14.3)|
| Married|| 96 (74.4)||20 (64.5)||76 (77.6)|
| Divorced|| 8 (6.2)|| 0|| 8 (8.2)|
|Orchidectomy||128 (99.2)||31 (100)||97 (99.0)|
|RPLND|| 83 (64.3)||23 (74.2)||60 (61.2)|
|Radiation|| 21 (16.3)|| 4 (12.9)||17 (17.3)|
|Chemotherapy|| 67 (51.9)||17 (54.8)||50 (51.0)|
|Had children before Dx|| 65 (50.4)||10 (32.3)||55 (56.1)|
| Mean (range) number of children before Dx|| 2.05 (1–5)|| 1.5 (1–3)|| 2.15 (1–5)|
|Had children after Tx Mean (range) number of children after Tx|| 28 (21.7) 1.29 (1–2)|| 14 (45.2) 1.36 (1–2)|| 14 (14.3) 1.21 (1–2)|
|Total having children|| 80 (62.0)||15 (48.4)||63 (64.3)|
Men who banked sperm were less likely to have had children before diagnosis (P < 0.025) and more likely to have children after treatment (P < 0.01) than those who did not. At the time of survey, there was no difference between the groups in the number of patients having children.
Overall, 31 of 129 respondents (24%) banked sperm. Of these, two (6.5%) had used their samples to conceive a child, one has not used his sperm but indicated that he might in the future, and 28 men either did not use their banked sperm or indicated that they did not intend to use it. Of these, 12 men (39%) had children naturally, without using their banked samples.
Before their testicular cancer diagnosis, 64 men (50%) had not had children. Of these, 21 (33%) chose to bank their sperm. Two of these (3%) used their samples to have a child and 13 (20%) had a child without using banked sperm.
Men who declined sperm banking gave 12 general responses, grouped for convenience. The most common reason was not wanting to have more children, followed by being infertile, having an infertile partner, or having had a vasectomy; other responses are listed in Table 2.
Table 2. Reasons given for declining sperm donation and storage
|Did not want to have (more) children||17|
|Felt donation was not necessary or advised donation was not necessary|| 5|
|Religious reasons/‘Let nature take its course’|| 5|
|Can not remember/unknown|| 5|
|Too expensive|| 3|
|Too old to have children|| 3|
|Mentally handicapped and not intending to have children|| 2|
|Single at time of diagnosis/treatment|| 2|
At the time of survey, 49 of 129 (38%) respondents did not have children, and an attempt was made to ascertain if they had been unable to have children despite efforts to do so. One man (2%) indicated that he had tried unsuccessfully to have a child and six (12%) did not know their fertility status. Of the others, 21 were single and stated that they had not tried to conceive a child. Table 3 describes the after-treatment fertility in the present patients.
Table 3. Fertility after treatment
|Number of patients:|
| who have not had children to date||49/129|
| who did not donate sperm||35|
| who tried to have children but have not succeeded|| 1|
| whose fertility status unknown|| 6|
|Reasons given for not trying to have children:|
| Not ready yet|| 6|
| Too old|| 5|
| Infertility/previous vasectomy|| 5|
| Do not want children|| 3|
| Mental handicap|| 2|
The cost of sperm banking was reported to include a mean initial fee of US $358 (median 300, range 0–1000) and a mean annual maintenance fee of $243.86 (median 300, range 0–1200).
As most men treated for testicular cancer are young and have a favourable prognosis, the issue of after-treatment fertility is important, particularly in men receiving additional therapy. RPLND can impair fertility by causing failure of emission, retrograde ejaculation, or both. However, nerve-sparing RPLND, when performed at a centre of excellence, should allow preservation of ejaculation in > 90% of cases , and ≈ 75% of men treated with RPLND for clinical Stage I disease will be able to achieve paternity . Chemotherapy damages germinal epithelium, and the degree and speed of recovery of spermatogenesis after therapy is directly related to the dose and character of the agent received . The use of cisplatin-based regimens causes azoo- and oligozoospermia in most men, with 80% achieving normospermia within 5 years of treatment . Fears of teratogenesis in the offspring of men treated with chemotherapy for testicular cancer have not been realised to date. Radiation-induced testicular damage is similarly dose-dependent, as is the time to and extent of recovery of testicular function. At doses of > 400 cGy, recovery of spermatogenesis takes ≥ 5 years, while only 9–18 months is needed for doses of <100 cGy .
Despite these promising statistics, up to 25% of men can be permanently azoospermic after treatment . Hence, it is our practice to counsel all patients before treatment and to recommend the use of sperm banking. Several groups reported that the effects of cryopreservation on sperm quality in men with testicular cancer are identical to effects in fertile men with no cancer [8–10]. Hallak et al.  also reported that neither increasing stage of cancer nor histological features affected sperm quality in men with testicular cancer.
In the present study, men who chose to bank sperm were more likely to be younger, single, and not to have had children before diagnosis. These characteristics probably caused them to put a higher priority on fertility than those patients who chose not to bank sperm. The most common reason for not banking sperm was not wanting to have more children, followed by being infertile, having an infertile partner, or having had a vasectomy.
Overall, the use of cryopreserved sperm in the 31 men who banked sperm was low, with <10% (three of 31) claiming to have used or planning to use their sperm. Furthermore, a substantial number of men who banked sperm achieved impregnation after treatment without using banked sperm (12/31, 39%). Of the 48 men who did not bank sperm, six have had children after treatment, and only one has been unable to achieve paternity despite attempts to do so.
The present study has several weaknesses; the relatively few patients and the retrospective nature of the analysis are limitations. However, we think that this is the first publication specifically addressing the use of sperm banking in men with testicular cancer. The lack of validation of our questionnaire could also be construed as a weakness, but we think that it was well suited for our goal.
In conclusion, although we recommend discussion of sperm banking before adjuvant treatment in all men with testicular cancer, only a minority of men in the present study chose to bank sperm (24%). Men who were younger, single, and had not yet fathered children were most likely to bank sperm. Among these, the use of the banked sperm was very low (<10%) and many men had children without using banked sperm. Given the relatively high costs of sperm banking and the low rate of use, men should be counselled on the costs and benefits of sperm banking before treatment for testicular cancer.
CONFLICT OF INTEREST