How to Protect Your Fertility and Plan for Your Future Family
by John Lindsey, MD, Heiko Yang, MD, PhD, and James F. Smith, MD, MS
The American Cancer Society estimates that by January 2024, there will be more than 9.3 million male cancer survivors in the U.S. One of the most significant side effects facing these men diagnosed with cancer is irreversible damage to the male reproductive system, which can lead to a reduced ability – or even inability – to have children. For these men, fertility preservation should be an integral part of their cancer care.
Fertility Preservation – What You Need to Know Before Starting Treatment
For men diagnosed with cancer, sperm banking, also known as cryopreservation, should be performed prior to starting cancer treatment. Ideally, one or more semen samples should be banked. The frozen sperm can later be used for intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic sperm injection (ICSI).
- IUI requires at least 5 to 10 million sperm, which are placed inside the female partner’s uterus.
- With IVF, the harvested sperm (ideally 50,000 to100,000 sperm) are introduced to an egg in a laboratory dish to allow for fertilization. The fertilized embryo is then transferred to the partner’s uterus.
- ICSI (pronounced “ick-see”) is the direct injection of one sperm into one egg for fertilization, followed by transfer of the embryo to the uterus.
On average, each milliliter of ejaculate contains more than 15 million sperm. However, it is important to remember that it may take more than one ejaculation to produce enough sperm to fully ensure your ability to have children in the future.
To increase your chances of fathering a child after cancer, it’s best to discuss your fertility preservation options before starting treatment.
If a person cannot provide ejaculated sperm, a minor operative procedure – known as testicular sperm extraction (TESE) – can be done to surgically remove sperm from the testicles. For pre-pubertal boys and young men who do not yet produce sperm, there is no standard option for fertility preservation. For these cancer survivors, pre-treatment testicular tissue collection and freezing (cryopreservation) is a promising technique that is currently being offered in clinical research studies.
Evaluating Your Fertility Options After Cancer Treatment
After cancer treatment is completed, male cancer survivors have several fertility options that can help them father children. Depending on the number of healthy sperm in the ejaculate, spontaneous conception may still be a possibility. A semen sample can be sent to a laboratory for assessment to help answer this question. Ideally, the total sperm count should be higher than 40 million, with good motility (movement as judged by the technician in a laboratory) per ejaculate. If the sperm count is lower than this, IUI, IVF, or ICSI may be recommended.
How long after finishing cancer treatment should I wait before trying to father a child?
Sperm counts are lowest four to six months after radiation and chemotherapy and can take years to return to more normal values. Most doctors recommend waiting for up to twelve months after cancer therapy to ensure that the sperm are as healthy as possible before trying to conceive.
If there are no sperm in the ejaculate, it is possible that the sperm are being emitted backwards into the bladder (called retrograde ejaculation), rather than being propelled from the tip of the penis, during ejaculation. This may occur after certain types of surgery, when taking specific medications, or with particular medical conditions. Specialized testing can diagnose this issue. If you have retrograde ejaculation, sperm can still be collected and used for IUI, IVF or ICSI.
If no sperm are found in the ejacu late or in the urine after ejaculation, it is possible that very small numbers of sperm remain in the testicles. A surgical procedure, called a microsurgical testicular sperm extraction (Micro- TESE), may be done to find individual sperm for use in ICSI.
For men diagnosed with cancer, sperm banking, also known as cryopreservation, should be performed prior to starting cancer treatment.
For men who have no identifiable sperm, using donor sperm to achieve pregnancy may be an option. Donor sperm is typically anonymously donated to a sperm bank by a healthy man after he is screened for infectious diseases. The characteristics of the sperm donor are typically recorded and available for review so that the recipient can match the donor’s appearance to their own if desired.
Lastly, adoption is another possibility for couples or individuals who desire a child. Through adoption, the adoptive parents become the permanent legal guardians of the adopted child. Different agencies (private and public), governmental authorities, and countries have varying requirements for adoptive parents. Some may require notification from a doctor saying that the adoptive parents are in good health. Additionally, cancer survivors may be required to observe a waiting period after finishing cancer treatment before they can begin the adoption process. Adoptions may be open, where the birth parents and adoptive parents may communicate, or they may be closed, in which case parental details are kept secret.
If you’ve been diagnosed with cancer and are concerned about preserving your fertility, talk to your doctor right away. Write down any questions you have and bring them with you to your appointment. To increase your chances of fathering a child after cancer, it’s best to discuss your fertility preservation options before starting treatment. You may want to consider getting a referral to a reproductive urologist, even if you are uncertain about having a family in the future. Doing so will ensure that all your fertility options will be open to you after treatment.
Dr. John Lindsey (first) and Dr. Heiko Yang (second) are medical residents in the Department of Urology at the University of California, San Francisco.
Dr. James Smith is associate professor of Urology; Obstetrics, Gynecology, and Reproductive Sciences; and Health Policy, as well as the director of Male Reproductive Health, also at UCSF in San Francisco, CA.