Male Infertility

Source: Livestrong

This document was produced in collaboration with Leslie R. Schover, PhD Professor of Behavioral Science The University of Texas M.D. Anderson Cancer Center

 

Some male cancer survivors find that they are not able to have children due to the effects of cancer treatment. By identifying your risk for infertility, you can take steps before treatment to preserve your fertility. For survivors who have already completed treatment, there are other options for having children.

Male Infertility: Detailed Information

This information is meant to be a general introduction to this topic. The purpose is to provide a starting point for you to become more informed about important matters that may be affecting your life as a survivor and to provide ideas about steps you can take to learn more. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Suggestions and Additional Resources sections for questions to ask and for more resources.

Cancer and treatment may put survivors at risk for infertility. Male infertility generally means an inability to produce healthy sperm or to ejaculate sperm. Although sperm production recovers after cancer treatment in many men, it is not possible to predict what will happen for any individual person. Because sperm can be preserved and frozen for future use, it is crucial to discuss the risks of infertility with your healthcare provider before cancer treatment begins. This allows you to be able to take advantage of sperm banking if you choose. Once a man begins chemotherapy or radiation to the pelvic area, his sperm cells may have genetic damage. Banking them and using them later to conceive a child may increase the risk of birth defects, although few statistics are available.

There are some treatment options for survivors who experience infertility as a result of cancer or treatment. Set up an appointment with a member of your health care team to discuss any concerns or questions you may have. Keep in mind that you can ask for a referral to a fertility clinic or specialist for help with this important issue.

Learning that you could be or actually are infertile can be distressing. Not only may you have more difficulty having biological children, but you may worry about the impact on your relationship or feel a loss of self-esteem. This document outlines the physical causes of infertility and options for survivors who experience difficulty having children. It does not discuss the emotional effects. Talk with your health care provider if you think that infertility may be having an impact on your emotional well-being and consider whether a support group or some counseling could be helpful.

What causes infertility in men?

Fertility in men can be affected by a number of factors including:

  • Genetic: Male infertility can be inherited, especially when Y-chromosomes are missing a tiny piece of genetic code. Men who have genetic causes of infertility may pass the problem to their sons if they are able to father a child through infertility treatments. Some gene mutations also block the development of the tubes that carry sperm to the area where they mix with the semen.
  • Hormonal: Men whose hormones are out of balance can become infertile. This can sometimes be related to cancer or treatment.
  • Physical: There may be physical reasons such as blockages of the tubes that form the pathway for sperm to travel to the area where they mix with the semen. Blockages can be caused byscar tissue after injury or infection. These tubes are blocked or cut in a vasectomy, the operation to prevent a man from fathering children. Lower Varicoceles (clusters of enlarged veins in the testicles) can keep the temperature of the testicles too high, affecting the growth of healthy sperm.
  • Disease-related: Some diseases or illnesses can cause lower sperm counts such as diabetes, mumps orchitis or tuberculosis.
  • Environmental: Exposure to environmental factors can affect fertility such as high heat, radiation or pesticides.
  • Lifestyle factors: Obesity, tobacco use, heavy drinking or using anabolic steroids for body-building can affect fertility.
  • Age: Semen quality may decrease somewhat with age, although the impact of age is not as strong as it is on women’s fertility.
  • Cancer and treatment for cancer: Some types of cancer temporarily lower a man’s fertility. More commonly, it is cancer treatment that interferes with a man’s fertility, either temporarily or permanently.

 

Which cancers are most likely to cause male infertility?

Some cancers are more likely to cause male infertility such as:

  • Testicular cancer: Fertility may be poor during the two years before testicular cancer is discovered. Although only 1 to 3 percent of men with testicular cancer get cancer in both testicles, the cancer-free testicle may not be totally normal. On the other hand, men treated for testicular cancer often end up with improved semen quality within several years.
  • Newly-diagnosed Hodgkin’s disease, lymphoma or leukemia: Recent surgery, fever or physical stress experienced by survivors may affect the quality of semen.

 

Which cancer treatments are most likely to cause male infertility?

Cancer treatment, not cancer itself, is often the factor that damages a man’s fertility. For example, radiation and chemotherapy treatments kill cells that are in the middle of dividing and growing at a time when they may be more easily damaged. Cancer cells divide much more often than most normal body tissues, so they are killed off while normal cells survive. However, hair and sperm cells are more sensitive to chemotherapy and radiation because they grow constantly.

Some of the concerns for specific types of treatment follow:

Radiation Therapy

  • Radiation therapy can slow down or stop sperm cell production if the testicle is in or near the target area for the radiation. A lead shield can help protect the testicles during radiation aimed at a nearby organ such as the prostate, but radiation “scatters” within the body so it is not possible to shield the testicles completely.
  • Total body irradiation used before some bone marrow transplants often causes permanent infertility.
  • If the testicles get a mild dose of radiation, a man’s fertility may drop but can then recover over the next one to four years.
  • If the radiation dose to the testicles is high, sperm production may stop forever. This happens because the spermatogonia are destroyed. These are the stem cells in the testicles that divide and grow to produce mature sperm. Some boys treated for acute leukemia need to have radiation directly to the testicles. Not only their sperm production, but their hormones may be permanently damaged.
  • Radiation damage to the part of the brain that controls hormone production can sometimes interfere with the hormone messages that control sperm production in the testicles.

Chemotherapy

  • The alkylating chemotherapy group does the most damage to fertility. These drugs include cyclophosphamide (Cytoxan), chlorambucil (Leukeran), busulfan (Myleran), procarbazine (Natulan, Matulane), nitrosoureas (Carmustine, Lomustine), nitrogen mustard (Mustargen), and L-phenylalanine mustard (Alkeran).
  • In high doses, platinum-based chemotherapy (Cisplatin, Oxaliplatin) or drugs like bleomycin (Blenoxane, Bleomycin), often used to treat testicular cancer, can also damage fertility.

Surgeries

  • Radical surgery to treat prostate or bladder cancer removes the prostate and seminal vesicles. These glands make the liquid part of a man’s semen. They also cut the pathway for sperm cells to be included in the semen.
  • Men with testicular cancer or colon cancer sometimes have surgery that can damage nerves involved in orgasm. The result may be a “dry orgasm” or the sensation of pleasure, but without ejaculating any semen.
  • A man is at higher risk for infertility if he gets two or more alkylating chemotherapy drugs, has higher doses of chemotherapy (for example before a stem cell or bone marrow transplant), or has a combination of chemotherapy and pelvic or whole body radiation.
  • In addition to directly damages sperm cell production, high doses of chemotherapy can damage the testicles’ ability to make testosterone. This hormone is crucial in a man’s fertility.

 

What are symptoms of male infertility?

Men usually do not have any symptoms of infertility unless they have dry orgasms. They generally do not realize that they are infertile until they have a semen analysis and discover that the semen quality is low. If you are curious about your own fertility, talk to your health care provider about being tested.

How can a man’s fertility be tested?

A semen analysis tests a man’s fertility. A sample is collected very soon after ejaculation and examined under a microscope. The analysis usually includes at least three scores that define semen quality:

  • The sperm count is the number of sperm present. A normal count is at least 20 million sperm per milliliter of semen.
  • The motility is the percentage of sperm that are actively swimming around. At least 50 percent of the sperm should be motile.
  • The morphology is the shape of the sperm. It is considered normal if at least 30 percent of the sperm have an ideal shape. Some labs use a different (Kruger) scoring system which is stricter—only 14 percent of sperm cells need to have an ideal shape with this system.

 

When does cancer-related infertility start and how long does it last?

Infertility is most likely to happen before cancer treatment and just after treatment is finished. It is possible that an analysis may say you are infertile, yet the results may change over the next month or even years.

If a man is going to recover sperm production, his semen analysis will usually improve within one to three years after he finishes cancer treatment. However, some men have had improvements many years later. A man should not count on an abnormal sperm analysis in making decisions about using effective means of birth control.

What are some options for a man whose fertility was or will be affected by cancer or treatment?

Options for men who have concerns about the effect of cancer or treatment on fertility include:

  • Sperm banking
  • Testicular tissue freezing
  • Donor sperm
  • Adoption

 

Works Cited

Anserini, P., S. Chiodi, S. Spinelli, et al. “Gonadal Function Post Transplantation: Semen Analysis following Allogeneic Bone Marrow Transplantation. Additional Data for Evidence-Based Counseling.” Bone Marrow Transplantation 30 (2002): 447-51.

Bahadur G, Ozturk O, Muneer A, Wafa R, Ashraf A, Jaman N, Patel S, Oyede AW, Ralph DJ. Semen quality before and after gonadotoxic treatment. Human Reproduction 20 (2005):774-81.

Chan PT, Palermo GD, Veeck LL, Rosenwaks Z, Schlegel PN. Testicular sperm extraction combined with intracytoplasmic sperm injection in the treatment of men with persistent azoospermia postchemotherapy. Cancer92 (2001): 1632-7.

Eskenazi, B., A.J. Wyrobek, E. Sloter, et al. “The Association of Age and Semen Quality in Healthy Men.” Human Reproduction 18 (2003): 447-54.

Frias, S., P. Van Hummelen, Marvin L. Meistrich, et al. “NOVP Chemotherapy for Hodgkin’s Disease Transiently Induces Sperm Aneuploidies associated with the Major Clinical Aneuploidy Syndromes Involving Chromosomes X, Y, 18, and 21.” Cancer Research 63 (2003): 44-51.

Golombok, Susan, F. MacCallum, E. Goodman, M. Rutter. “Families with Children Conceived by Donor Insemination: A Follow-Up at Age Twelve.” Child Development 73 (2002): 952-68.

Hjelmstedt, A., L. Andersson, A. Skoog-Svangerg, et al. “Gender Differences in Psychological Reactions to Infertility among Couples Seeking IVF- and ICSI- Treatment.” Acta Obstetrica Gynecologica Scandinavica 78 (1999): 42-8.

Kiserud CE, Schover LR, Dahl AA, Fosså A, Bjøro T, Loge JH, Holte H, Yuan Y, Fosså SD. Do male lymphoma survivors have impaired sexual function? Journal of Clinical Oncology 27 (2009): 6019-26.

Pasch, Lauri A., Christine Dunkel-Schetter, Andrew Christensen. “Differences between Husbands’ and Wives’ Approach to Infertility Affect Marital Communication and Adjustment.” Fertility and Sterility 77 (2002): 1241-7.

McIntosh, G. C., A. F. Olshan, P. A. Baird, et al. “Paternal Age and the Risk of Birth Defects in Offspring.”Epidemiology 6 (1995): 282-8.

Schover, Leslie. Overcoming Male Infertility: Understanding Its Causes and Treatments. New York: John Wiley & Sons, 2000.

Shaw, Gina. Having Children After Cancer: How to Make Informed Choices Before and After Treatment and Build the Family of Your Dreams. Berkeley, CA: Celestial Arts, 2011.

Yogev L, Kleiman SE, Shabtai E, Botchan A, Paz G, Hauser R, Lehavi O, Yavetz H, Gamzu R. Long-term cryostorage of sperm in a human sperm bank does not damage progressive motility concentration. Human Reproduction 25 2010): 1097-103.

Wyns C, Curaba M, Vanabelle B, Van Langendonckt A, Donnez J. Options for fertility preservation in prepubertal boys. Human Reproduction Update 16 (2010): 312-28.

 

Male Infertility: Suggestions

The suggestions that follow are based on the information presented in the Detailed Information document. They are meant to help you take what you learn and apply the information to your own needs. This information is not intended nor should it be interpreted as providing professional medical, legal and financial advice. You should consult a trained professional for more information. Please read the Additional Resources document for links to more resources.

The following are fertility options that may be available for male cancer survivors:

Sperm Banking

How it is done:

  • Before beginning chemotherapy or radiation, a man produces a semen sample either at a medical laboratory or sperm bank or in privacy at home. Masturbation is the preferred method, since even using a condom during intercourse could leave the semen contaminated with bacteria. Samples produced at home need to be kept at body temperature and delivered to the lab within an hour. Some sperm banks provide kits a man can use at home, mixing a preserving chemical with his semen and using overnight mail to the lab. Some loss of semen quality is likely with this method but it can be helpful for men who live in a rural area or have other problems getting to the lab.
  • A semen analysis is done. As long as the sample contains some live sperm cells, it can be frozen and stored for future use in infertility treatment.
  • Once frozen, samples can be kept for at least 20 to 30 years (possibly longer) without further damage.

Cost: Most health insurance plans do not cover the cost of storing frozen semen. They also may not pay for the semen analysis if it is known to be part of the banking process. Many sperm banks have monthly payment plans to make banking more affordable.

Who can do it: Males who have reached puberty (even as young as age 12 or 13) can bank sperm for as long as the semen contains enough live and healthy sperm.

Where to bank sperm: Most large cities have sperm banks that can be found on the internet. A member of your oncology health care team should also be able to give you a referral. Many sperm banks will work with a local laboratory to process your sample and send it for analysis and long-term storage.

 

Freezing Tissue from the Testicle in Boys Who Have Not Reached Puberty

How it is done:

  • If a boy is too young to be producing sperm cells but will have a high risk of infertility after his cancer treatment, an experimental option is to put him under anesthesia for an outpatient surgery, remove several areas of tissue from his testicles, and freeze that tissue for future use.
  • Once he is an adult and free of cancer, if he is indeed infertile he could use the tissue in one of several ways. None of these methods has yet produced the birth of a live baby, however.
  • The tissue pieces could be thawed and put back into his testicle in the hopes that they would begin to produce sperm. This is a delicate process that would only work if his hormones were normal and his testicles were at a good temperature with a good supply of blood circulation.
  • The tissue pieces could be thawed and transplanted into the body of a mouse specially bred to have no immune system. If mature sperm cells grew, they would be gathered to use in infertility treatment. So far, researchers have not been able to grow human sperm all the way to maturity with this method. Also, there is a small concern that viruses from the mouse could be passed on through the sperm to the mother or baby.
  • The tissue pieces could be thawed and the spermatogonia, stem cells that grow mature sperm, could be separated out. A fluid containing the spermatogonia could be injected into the grown man’s testicles in the hopes that they would be able to produce generations of sperm.

Who Can Do It: Only a few infertility and cancer centers offer testicular tissue freezing. Most boys who have cancer treatment do not try to preserve their fertility. Until tissue freezing produces successful births, it should be offered as a research option, with the parents signing an informed consent form. Some research programs have funds to cover the costs of getting and storing the tissue, which is important since the procedure is expensive and may never be helpful.

When less than 2 million sperm cells are available for infertility treatment, the usual choice is to use them in In Vitro Fertilization with Intracytoplasmic Sperm Injection (IVF-ICSI).

 

In Vitro Fertilization – Intracytoplasmic Sperm Injection (IVF-ICSI)

How it is done:

  • The woman who will carry the child must undergo hormone shots for several weeks to stimulate her ovaries to ripen more than one or two eggs.
  • The woman’s eggs are harvested or collected through a minor outpatient surgery.
  • The harvested eggs are cleaned in the laboratory and stored in individual dishes to be ready for fertilization.
  • The embryologist uses a special microscope to choose a healthy-looking sperm and injects it into an egg. If all goes well, several embryos can be created.
  • Usually just one or two embryos are placed into the uterus of the female partner in the hopes that they will implant and start a pregnancy.

Cost: IVF-ICSI is expensive and involves some medical risks for the woman. However, it is also very successful, especially if the woman has normal fertility and is younger than age 35.

Who can do it: Since only a few sperm are needed, IVF-ICSI is a good option for men who have poor semen quality or have sperm with poor motility.

 

Intrauterine Insemination (IUI)

This option is for men with semen quality that is closer to normal.

  • A man’s semen sample is purified and concentrated to contain as many active sperm as possible.
  • In a health care provider’s office, the sample is put in a thin catheter (tube) and slipped directly through the woman’s cervix into her uterus to give the sperm a head start on fertilizing the egg.
  • The procedure is done at a woman’s midcycle, her fertile time of month. Sometimes the woman is given extra hormones to ripen more than one egg, but not in the high doses used in IVF. This is called superovulation. If an ultrasound shows that too many eggs are ripening, the insemination should either be canceled or the woman should have her eggs gathered and used for IVF instead. Otherwise there is a high risk of a multiple pregnancy, with all of its dangers for the mother and infants.

 

Donor Insemination

  • A man donates his sperm. The survivor may choose someone that is known personally or much more commonly, the man or couples chooses a sperm donor who has worked with a donor sperm from a sperm bank. may be used. The donor may be similar to the man in ethnic background, coloring, etc. Most sperm donors in the United States prefer to remain anonymous, but many give the bank information about their hobbies and personalities. Their family and personal health histories are analyzed carefully to minimize the chance of an inherited disease.
  • The semen is used as in IUI to create a pregnancy

 

Adoption

  • Adoption is accepting legal responsibility for an orphaned child. Contact an adoption agency for more information. Adoption has become difficult as more young, single women keep their babies. Many international countries will not allow a cancer survivor to adopt, but some will accept a letter from the oncologist stating that the survivor is healthy, with a normal expected life span. Most adoptions in the United States are independent, arranged by an attorney. Birth mothers often choose the adoptive parents from many “profiles” they receive. Domestic agencies vary in how open they are to working with cancer survivors.

Cost: The process can be expensive ($5,000 to $40,000) and may take a long time.

Who can do it: Adoption agencies have screening processes for anyone who wants to adopt. Talk with your health care team about getting any documentation that may be needed to confirm that you are healthy and able to care for a child.

 

Male Infertility: Additional Resources

The previous sections of this document provide detailed informationsuggestions, and questions to ask related to this topic. This section offers a listing of additional resources that are known to provide support and quality services that may be helpful to survivors during the cancer journey.

LIVESTRONG Care Plan
www.livestrongcareplan.org

This free online tool was created to help you develop a personalized plan for post-treatment care. It can help you work with your oncologist and primary health care provider to address medical, emotional and social challenges that may arise after cancer treatment is completed. By answering some questions related to your cancer treatment, you will receive information about your follow-up care. This information includes symptoms to watch for in the future and steps you can take to stay healthy.

 

LIVESTRONG Cancer Navigation Center
www.LIVESTRONG.org/GetHelp

Email: Cancer.Navigation@LIVESTRONG.org
Phone: 1.855.220.7777 (English and Spanish)
Navigators are available for calls Monday through Friday, 9 a.m. to 5 p.m. (Central Time). Voicemail is available after hours.

The Navigation Center provides free, confidential one-on-one support to anyone affected by cancer. This is not a medical facility, but rather a center that provides the following support services:

  • Emotional Support—assistance coping with a cancer diagnosis, help accessing support groups, as well as peer-to-peer connections
  • Fertility Risks and Preservation Options—information on fertility risks and help accessing discounted rates for fertility preservation options
  • Insurance, Employment and Financial Concerns—information on employment rights and benefits, financial assistance and debt management, including insurance and billing issues as well as medication co-pay assistance

In addition to professional cancer navigators on staff, LIVESTRONG partners with specialty organizations such as Patient Advocate Foundation, Imerman Angels, Navigate Cancer Foundation and EmergingMed to provide support services.

 

Cancer Hope Network
www.cancerhopenetwork.org

Email: info@cancerhopenetwork.org
Phone: 1-800-552-4366
This number is answered Monday-Friday, from 8:00 a.m. to 5:30 p.m. (EST). Voicemail is available after hours.

Cancer Hope Network is a not-for-profit organization that provides free and confidential one-on-one support to cancer patients and their families. They offer support by matching cancer patients or family members with trained volunteers who have already undergone and recovered from a similar cancer experience. You can submit your request by phone or by email. A volunteer will try to contact you within 24 hours.

 

Fertile Hope
www.fertilehope.org

Email: fertilehope@fertilehope.org
Phone: 1-888-994-2353

Fertile Hope is a national, nonprofit organization dedicated to providing information, support and hope to cancer patients whose medical treatments present the risk of infertility. Fertile Hope works with cancer patients and survivors through programs of awareness, education, financial assistance, support and research. Fertile Hope produces a wide array of free publications for you to read or order. You can also download transcripts from lectures, teleconferences and events.

 

Oncofertility Consortium 
www.Oncofertility.northwestern.edu

Phone: 1-866-708-3378

The Oncofertility Consortium is a group of researchers and medical professionals dedicated to exploring and expanding options for the reproductive future of cancer survivors. The online patient education resources includeMyOncofertility.org, which provides information and tools to educate patients and families about fertility preservation options before, during and after cancer treatment and SaveMyFertility.org, which provides printable FAQs for men, women, and children. The Oncofertility Consortium has also created the first iPhone App on cancer and fertility, iSaveFertility. For up-to date information about reproductive health and cancer, follow the Oncofertility blog (blog.oncofertility.northwestern.edu). Patient navigators are available for free informational consultations and referrals via the FERTline, (866) 708-3378.

 

RESOLVE: The National Infertility Association
www.resolve.org

Email: info@resolve.org
Phone: 1-703-556-7172

RESOLVE: The National Infertility Association provides support, education and advocacy to those dealing with infertility. The website provides timely information related to all family building options, including assisted reproductive technology, third-party donors, adoption and living child-free. The website offers information about local RESOLVE support groups, educational events and facts about state insurance coverage for the diagnosis and treatment of infertility. There are also a variety of RESOLVE publications and online social networking communities.

 

Society of Assisted Reproductive Technology (SART)
www.sart.org

Email: kjefferson@asrm.org
Phone: 1-205-978-5000, ext. 109

The Society for Assisted Reproductive Technology is an organization of medical professionals who treat infertility. SART promotes and advances the standards for the practice of assisted reproductive technology. The website includes information on assisted reproductive technologies, such as in-vitro fertilization, gamete intrafallopian transfer and tubal embryo transfer. Information includes step-by-step descriptions of some procedures and a look at both the financial and emotional effects of assisted reproductive technology. The site also includes a search tool to find practitioners in your area and links to other resources.

 

The Adoption-after-Cancer Online Yahoo Group
groups.yahoo.com/group/adoption-after-cancer/

This online bulletin board includes many cancer survivors who have successfully adopted as well as questions from people just starting the process. You can read through the archives to find agencies and home study workers whore open to working with cancer survivors.