| The Testicular Cancer Resource Center |
Testicular Cancer and fertility are interrelated in numerous ways.
Fertility problems are usually complex and when TC is involved, they can become even more complicated. Since any number of things can cause fertility problems, it would be hard for us to cover each and every one. This page attempts to cover the major issues and provide links to other sites on the web with more information.
Sperm Banking:
So, you are about to have treatment and you would like to bank some sperm. How do you go about it? Start by asking your urologist or oncologist for a referral to a fertility center or sperm bank. This can usually be arranged quickly, and some programs now offer remote collection or shipping if there is not a convenient local facility. You can also take a look at the Fertility Links page.
Once you have identified a sperm bank or fertility center, you may or may not be shocked at the price of preserving and storing your sperm. Some sperm banks charge astronomical rates, while others are quite reasonable. If there is more than one facility nearby, the odds are better that their rates will be competitive. It might pay to negotiate with them on the subject if your insurance will not cover the procedure. Will your insurance cover sperm banking? You definitely should ask ahead of time. Coverage varies considerably by insurance plan and by where you live.
Even if it is not covered, consider the cost of preserving and storing your sperm as insurance. If fertility does not recover after treatment, having sperm already stored may preserve options and avoid the need for more complicated and expensive procedures to retrieve sperm later.
Fertility and the Orchiectomy:
As I mentioned, many men who have testicular cancer also already have fertility problems. In some, the orchiectomy alone will clear things up quite a bit. However, in others the situation may get no better or might even get worse.
For the vast majority of men, the orchiectomy will not introduce any fertility problems. The orchiectomy should not be unnecessarily delayed, but if future fertility matters to you, it is reasonable to ask about sperm banking before surgery. This is particularly worth considering if either of your testicles was ever cryptorchid (undescended) or if one of them is atrophic (it has atrophied due to disease or has always been much smaller).
Fertility and the RPLND:
The RPLND is performed in order to remove the lymph nodes in the retroperitoneum. Unfortunately, one of the side effects of the RPLND is retrograde ejaculation. When this happens, semen will no longer come out of the penis during ejaculation. Instead, it goes backward into the bladder. It is caused when the sympathetic nerves are severed during the operation.
In the early 1980's urologists developed a way to avoid this problem. They discovered that low stage cancer almost always follows a predictable path when it spreads. As a result, they found that they could limit the RPLND to a specific area of nodes, thus reducing the odds of severing the sympathetic nerves. This operation is known as a Modified Retroperitoneal Lymph Node Dissection. This approach substantially improved the chances of preserving normal ejaculation.
In the late 1980's and early 1990's, they tried a new approach. Increasing knowledge of the anatomy of the sympathetic nervous system in the retroperitoneum allowed the doctors to identify the nerves, and dissect them free of lymphatic tissue before removing any of the lymph nodes. This operation is known as a Nerve Sparing Retroperitoneal Lymph Node Dissection. Today, when nerve sparing is appropriate and the operation is performed by an experienced testicular cancer surgeon, well over 90% of men having a primary RPLND can retain normal forward ejaculation.
However, the RPLND is still a complex operation that is rarely done by most urologists. Even if you are planning to have this surgery done by one of our experts, it may still be a good idea to bank sperm.
Note that if this operation is being done after chemotherapy, the odds of sparing the nerves and preserving normal ejaculation are considerably diminished. In many cases, the chemotherapy will cause scarring in the region that will make it harder to identify and spare the nerves. However, the situation is not as hopeless as we once thought. Nerve-sparing surgery can sometimes preserve normal ejaculation even after chemotherapy, particularly when the residual mass is limited and the operation is performed at an experienced center.
If you have an RPLND, and you find yourself with retrograde ejaculation once it is done, are you sterile? Absolutely not. The RPLND itself usually does not stop the remaining testicle from making sperm; the problem is that the sperm may no longer come out normally. Certain medications can sometimes temporarily restore forward ejaculation. If that does not work, a fertility specialist may still be able to retrieve sperm for use with assisted reproduction such as IVF or ICSI. The important point is that losing normal ejaculation does not necessarily mean losing the ability to have biological children.
Fertility and Chemotherapy:
The chemotherapy regimens used to kill testicular cancer do a very good job, and it is the primary reason why guys with advanced cancer can still hope to become a father. However, the chemotherapy does such a good job because it is very good at killing germ cells. Since sperm are generated by germ cells, it stands to reason that there aren't going to be a whole lot of sperm after undergoing chemo. And, in fact, chemotherapy often results in very low sperm counts or azoospermia (the semen contains no sperm) during treatment and for a period afterward.
In some cases, the sperm will never return. But sperm production frequently recovers over time. After multi-drug cisplatin chemotherapy, sperm production has recovered in about half of men within two years and in most men within five years, although some remain infertile. Whether the sperm does or does not come back probably depends on the initial quality of the sperm before treatment. It also depends a lot on the amount of chemo received. The more chemo received, the less likely that fertility will ever return.
Please note, though, that the available evidence is reassuring: children conceived after their fathers have completed treatment do not appear to have an increased risk of birth defects. Sperm can be damaged during treatment and for a period afterward, however, so ask your oncologist how long you should wait before trying to conceive.
Because chemotherapy can cause infertility that lasts for months, years, or permanently, we strongly recommend sperm banking before chemotherapy begins whenever possible.
Fertility and Radiation:
Many people think that the radiation used to treat seminoma will also cause infertility or will somehow cause mutated sperm. Radiation can temporarily reduce sperm production because a small amount of radiation may scatter to the remaining testicle. On the other hand, children conceived after treatment do not appear to have an increased risk of birth defects.
It is true that high levels of radiation aimed directly at the testicle can cause permanent infertility. For example, radiation in the range of 18-20 Gy may be used to treat germ cell neoplasia in situ (GCNIS) in a remaining solitary testicle, and this treatment is expected to destroy sperm production. Obviously, if this is done it is essential to bank sperm before beginning treatment.
In the case of the adjuvant radiation used to prevent relapses of seminoma, however, the amount of radiation at the level of the testicles is nowhere near that high. The actual dose depends on the treatment field and how close it comes to the remaining testicle. Radiation treatment is much more precisely planned and delivered than it was 40 or 50 years ago, and testicular shielding can further reduce the amount of scatter radiation reaching the remaining testicle.
Even relatively low doses of scatter radiation can temporarily lower sperm counts. Depending on the dose received by the remaining testicle, recovery can take a year or two, and shielding can be used to reduce the exposure. If future fertility matters to you, sperm banking before radiation is still a sensible precaution. Ask your radiation oncologist how long you should wait after treatment before trying to conceive.
Links:
The TCRC Fertility Links page has a number of fertility related links and articles. If you are interested in exploring the subject further, we encourage you to visit that page.