The TCRC Fertility Page

Testicular Cancer and fertility are interrelated in numerous ways.

TC usually affects young men still in the process of having a family.

Many men with TC have few or no sperm at the time they discover they have TC.

All of the active treatments for TC (orchiectomy, RPLND, chemotherapy, and radiation) can directly or indirectly cause fertility problems.

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.

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. In most cases, the testicle is removed so quickly that there is not time enough to even think about fertility. Is this appropriate? For most guys, yes, it is. However, 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), then you might want to bank some sperm before going through with the orchiectomy.

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 technique prevented retrograde ejaculation in about 70% of patients.

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. When done properly, this operation can prevent retrograde ejaculation almost 100% of the time.

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. Additionally, when this surgery is attempted, it is more likely to be done to remove a large residual mass, and the full bilateral approach is used. In this case, it is almost impossible to preserve normal ejaculation.

If you have an RPLND, and you find yourself with retrograde ejaculation once it is done, are you sterile? Absolutely not. The sperm is still there, it just needs to be retrieved one way or another. It is possible that certain drugs may temporarily prevent retrograde ejaculation long enough to make a baby or bank some sperm. If that does not work, it may also be possible to recover the sperm from the bladder and then use the sperm in conjunction with artificial insemination, IVF or ICSI.

Fertility and Chemotherapy:

The chemotherapy regimens used to kill testicular cancer does 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 usually results in azoospermia (the semen contains no sperm) during therapy.

In some cases, the sperm will never return. But in most cases sperm counts will increase in the 24 to 36 months following the conclusion of treatments, and in about 50% of men, the levels will eventually return to normal. However, even after 5 years the sperm counts of some men will remain below normal. 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 experts do not believe that chemo has any affect on the quality of the sperm or causes congenital defects in children conceived after undergoing chemotherapy.

Because of the high probability of an indefinite period of infertility following chemotherapy, we strongly recommend that men facing chemotherapy bank some sperm before starting treatments.

Fertility and Radiation:

Many people think that the radiation used to treat seminoma will also cause infertility or will somehow cause mutated sperm. There is really no evidence that either will occur.

It is true that high levels of radiation aimed directly at the testicle (say 2000 rads) will render it completely sterile. However, this is only done to destroy carcinoma-in-situ, and even then it is really only done in Europe. 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 is dependent on how low they go with the external radiation treatment (XRT) fields into the pelvis. In the past they did tend to radiate some of the pelvic lymph nodes, but in recent years the tendency has been to move away from pelvic radiation.

With the standard XRT fields to treat seminoma, the scatter radiation doses to the testicle are in the order of a cumulative 60 rads. Doses of 100-200 rads may produce a temporary decrease in sperm counts, but no permanent damage. While fertility should not be an issue and there is no hard data to support this recommendation, some radiation oncologists may tell you to wait around 1 to 2 years before attempting to conceive, others might tell you to wait 6 months.

Sperm Banking:

So, you are about to have treatment and you would like to bank some sperm. How do you go about it? Unfortunately, I do not have a good answer to this question right now. I expect that if you ask your urologist, they should know the names of one or two places you could go. Nevertheless, it is possible that there may not be a local sperm bank. If you take a look at the Fertility Links page, a few sperm banks are listed that will take deposits via Federal Express.

Once you find a place, you may or may not be shocked at the price of preserving 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 banking sperm? You definitely should ask ahead of time. A lot of them will not. Of course, if they DO pay for fertility treatments, then it only makes sense that they pay for sperm banking since that will be much cheaper than trying to recover viable sperm at a later date. If they don't pay for fertility treatments, consider the price of sperm banking and storage as insurance against the much larger cost of some of the newer treatments.

Links:

The TCRC Fertility Links page has a large number of fertility related links and articles. If you are interested on exploring the subject even more, I encourage you to visit all of the links.