A recent article written for the International Urological Society meeting in Berlin on the 16th October 2011.
The true incidence of azoospermia in patients presenting with testicular cancer remains unknown; there are no reports of the results of semen analysis in which significant numbers of patients have been surveyed. The uptake of invitation to store sperm has been reported as approximately 50% (1) of all age groups, and the desire for children was recorded in 77% of patients who were childless at the time of diagnosis (2,3). Chung et al reported oligospermia in 28% of men who desired storage (4).
In our own series reported in this review from the Hammersmith Hospital, only 36 of 676 patients with testicular cancer who cryopreserved sperm recalled and used their specimens for some form of Assisted Reproductive Technology (ART); this represents only 5% of the sample. Of significance was the high pregnancy rate of 50% overall in the these cases, despite very low motile sperm counts in 80% of cases. It has been suggested that, in men presenting with azoospermia and testis cancer, a contralateral microTESE procedure should be offered; Our own experiences suggest that pateints require very careful counselling before we comit them, and the cryopreservation units to an open-ended and possibly ‘unfulfilled’ contract.
Natural fertility and spontaneous natural conception may be more likely than is generally assumed by Urologists and Oncologists.
We contacted 170 patients, who had stored sperm prior to orchidectomy, to enquire about fertility status. In this sub-group, the recall rate was approximately the same as in the group as a whole (4.4%). The live birth rate after diagnosis and treatment was 22%; the births were equally disposed between those with treated seminoma and non-seminomatous tumours.
The largest European study(5) reported that only 554 of 1433 long-term survivors of testicular cancer attempted conception; the natural conception rate in this group was 70%, representing 15% of the original sample. In our study, 19% of men had fathered at least one child prior to diagnosis, but there was no statistically significant correlation between those who had achieved pregnancy before and after treatment.
The implications of these data are interesting. The desire for paternity in this group of men, as evidenced by the numbers attempting paternity both naturally and by ART is less than might be expected from the ‘normal’ population of similarly aged men. The recall rate of cryopreserved specimens seems to be low, but when used for ART, live birth rates seem higher than might be expected.
The consequences of these observations underline the importance of counselling, particularly after sperm cryopreservation, and that units should maintain close contact with men after treatment. We suggest that, where possible, a further fertility evaluation should be offered as a pre-requisite to confirmed sperm storage. In our own facility, more than 90% of specimens remain ‘unused’ and the default position mandates continued storage, rather than to discard on the basis of a ‘unilateral’ decision.
Recent advances in techniques of microTESE in non-obstructive azoospermia might encourage Urologists to suggest an ipsilateral or contralateral testicular dissection at the time of orchidectomy in patients with azoospermia. In our practice, we do not advise contralateral microTESE when hypogonadism coexists with testicular tumour. When ipsilateral dissection is undertaken, the procedure is completed ex-vivo, and is preceded by a careful epididymal aspiration. Wherever possible, a specimen for formal histological examination should be sent separately from a site immediately adjacent to the point of successful sperm retrieval. At present, the coexistence of spermatogenesis and intraepithelial neoplasia or carcinoma in situ has not been observed in patients who had had successful microTESE from the tumour-bearing testis.
Finally, the issue of partial orchidectomy requires very careful consideration, and it behoves interested practitioners to reflect upon their experiences. As a means of preservation of fertility, the procedure, in the light of microdissection, cryopreservation and the subsequent increased succes of ART, can be questioned. Similarly, the maintenance of androgen levels can be relatively easily managed by replacement therapy. Even when we reserve partial orchidectomy for patients with tumours in solitary testis, and when multiple ipsilateral biopsies are negative, disease may remain in the patient with accompanying dis-ease in the surgeon.
The prospects for fertility in men with testicular cancer has certainly improved, indeed it may in any case have been better than we assumed, because the incidence of voluntary infertility has only been assessed indirectly, and without statistical rigour. The principal duty remains to counsel the patients with care, and to preserve fertility without prejudicing the effective treatment of the cancer.
Mr J W A Ramsay MS FRCS FRCS(Urol)
Consultant Urologist/Andrologist –
Imperial College Healthcare NHS Trust, Chelsea & Westminster & West Middlesex Hospitals
Lead Clinician, Private Healthcare Group, ICHNT
Director of Professional Affairs, Royal College of Surgeons of England