Preserving Fertility in Males with Cancer

Certain cancers and their treatment can affect fertility in males and females. When a person with cancer wants to have children after treatment ends, some planning is needed. Sometime this involves fertility preservation. Fertility preservation saves or protects eggs, sperm, or reproductive tissue so that a person can use them to have children in the future.

This information is for males with cancer. If you are a gay man or transgender person, please talk to your cancer care team about any needs that are not addressed here.

Why males with cancer might need fertility preservation

In males who were fertile before treatment and who get certain types of treatment, the body may not be changed or may recover naturally after treatment. In these men, it may be possible to keep or restore normal sperm production. Whether this happens depends on the patient's age, stage in life, type of cancer, type and dose of treatment, and other health problems he may have. Be sure to know if fertility problems are a risk based on your treatment plan and health status.

But for some males, this is not the case. Certain types of cancer surgery can remove organs needed for reproduction, and certain treatments might change hormone levels or cause DNA damage to sperm. This can result in some males being unable to father a child after treatment for cancer. In some cases, a male is not able to fertilize a female's egg (conceive a pregnancy). Or, sometimes there are sperm-related problems that affect the health of a pregnancy and cause it to not last long enough, meaning it might end in miscarriage. It's also possible for a child who is conceived by sperm with damaged (abnormal) DNA to inherit the abnormal DNA, sometimes resulting in serious and even life-threatening birth defects. Read more in How Cancer and Cancer Treatment Can Affect Fertility in Males. Some men may choose to take steps that might help preserve their fertility so they can try to have children after treatment.

It's best that discussions about preserving fertility take place before cancer surgery happens or before treatments begin. Don't assume your doctor or nurse will ask you if fertility is important to you. They don’t always remember to bring this up, so you might have to bring it up yourself.

It's also very important to talk to your cancer care team about unprotected sex both during and after cancer treatment. They may recommend waiting several months or longer before trying to have a child by natural means or until resuming unprotected sexual intercourse.

Experts recommend doctors who are part of the cancer care team be involved in talking about fertility with patients, including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, surgeons, nurses, and others. The experts recommend the following:

• The cancer care team should talk about any possible fertility problems that might happen due to treatment as early as possible, either before surgery or before treatment starts.
• Patients who are interested in fertility preservation, might be thinking about it, or want to learn more, should be referred to a reproductive specialist.
• The cancer care team should start talking about preserving fertility as early as possible, too, meaning before treatment starts.

Learn more about how you can start talking about fertility with your cancer care team in How Cancer and Cancer Treatment Can Affect Fertility and in How Cancer and Cancer Treatment Can Affect Fertility in Males.

Types of fertility preservation for adult males with cancer

Sperm collecting and banking

Sperm banking is an effective method of fertility preservation for males. It’s a fairly easy and successful way for men who have passed puberty to store sperm for future use. It’s usually offered before cancer treatment to males who might want to have children in the future but sometimes doctors might not mention this option. By storing sperm, male cancer patients can decide this issue later and leave their options open. If you know you might want to father a baby later, ask about it. Your doctor can refer you to a reproductive urologist for sperm banking, or the cancer care team might arrange it. You might be able to find a sperm bank yourself with an online search.

In sperm banking, a male provides one or more samples of his semen. Once the sperm bank gets the sample, they test it to see how many sperm cells it contains (this is the sperm count), what percentage of the sperm are able to swim (which is called motility), and what percentage have a normal shape (called morphology). The sperm cells are then frozen and stored. A sample can be provided by the following ways:

• Ejaculation. Semen collection done by masturbation is usually done in a private room at a sperm bank facility, or arrangements are made for the patient to bring a sample collected at home into the lab.
• Electroejaculation. Some males are unable to ejaculate due to stress, anxiety, or other psychological causes. Additionally, some young males who may have had no prior experience with masturbation might not be able to produce a semen sample. Other health conditions in adult males might cause the inability to ejaculate, too. For these patients, electroejaculation can be used to successfully stimulate the pelvic nerves that cause the release of sperm. The semen that is collected by an electroejaculation procedure can either be used immediately or cryopreserved for future use. 

• From urine. Sometimes nerves that are needed to ejaculate semen or close the valve at the entrance to the bladder are damaged during cancer surgery or radiation treatment. When this happens, the male might still make semen, but it might not come out of his penis at orgasm. Instead, it might flow  backward into his bladder (called retrograde ejaculation). Fertility specialists can try to collect sperm from the urine of these males and use these sperm to help achieve a pregnancy. These sperm can sometimes be placed into the female partner’s uterus at the time of ovulation using a small flexible tube called a catheter.

• Sperm extraction and aspiration procedures. These procedures are options for collecting sperm from men who do not have sperm in their semen, either before or after cancer treatments. There are a few ways this can be done, including: percutaneous epididymal sperm aspiration (PESA), microsurgical epididymal sperm aspiration (MESA), testicular sperm extraction (TESE), and micro-TESE.

Limitations to sperm banking

It's important to know sometimes sperm banking might not be an option. Here are some examples of those situations:

• Fast-growing cancers: If you have a fast-growing cancer like acute leukemia (AML or ALL), you may be too ill to produce semen samples before starting cancer treatment, and cancer treatment usually starts quickly for these leukemias. If you can manage it, having even one semen sample banked could allow you to have a biological child in the future.

• Infectious diseases: Many sperm banks do not accept samples from men who have HIV (the virus that causes AIDS) or hepatitis. There are many risks involved with this. But some sperm banks may have special storage areas for a higher storage fee.

• Costs: The average cost of storing sperm (about 3 samples) in a sperm bank is about $1,500 to $2,500 for 3 years. Insurance coverage may be available and banking costs vary greatly, so it’s important to compare different centers. Many sperm banks offer financing and payment plans for people with cancer. If ejaculation is not possible and other ways to collect sperm are needed, costs will be higher.

Successes using frozen sperm

The success rates of infertility treatments using frozen sperm vary and depend on the quality of the sperm after it’s thawed, as well as the health and age of the female who receives it. In general, sperm collected before cancer treatment is just as likely to start a pregnancy as sperm from men without cancer. It's important to stay hopeful because sperm banking has resulted in many pregnancies. Once sperm is stored, it’s usually good for decades.

Keeping in touch with your sperm bank

It’s important to stay in contact with the sperm bank so that yearly storage fees are paid and your address is updated. Some sperm banks will destroy and discard sperm samples when patients lose contact with them.

When you're ready to use stored sperm

Once a couple is ready to try getting pregnant, the frozen sperm can be sent to the fertility specialist working with the couple. Depending on tests to confirm the health of a female and the quality of the sperm, the thawed sperm can potentially be used. Some procedures include:

• Intrauterine insemination (IUI) in which the thawed sperm is inserted into a female's uterus using a long catheter during her most fertile time during a month. The fertility specialist works with the couple to figure out the best time to do the procedure.
• In vitro fertilization (IVF) and in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) are more involved than IUI. A female takes hormones and her eggs must be retrieved. With IVF, they are put in a sterile lab dish with several thousand sperm. The goal is for one of the sperm to fertilize the egg. With IVF-ICSI, a single sperm is injected directly into an egg to fertilize it. In both procedures, if the egg is fertilized, the embryo can be frozen or put back into the female's uterus to achieve a pregnancy.

Radiation shielding

Patients receiving radiation therapy should talk with their cancer team about the risks of infertility with the radiation treatment and the length of time they will need to avoid unprotected sexual activity afterward.

Radiation treatment can cause infertility through the permanent destruction of the sperm stem cells in the testicle. Testicular tissue damage is unavoidable if both testicles need to be directly radiated.  When the radiation is directed at other structures in the pelvic area, the x-rays can often scatter and thus result in indirect testicular injury.

Fertility may sometimes be preserved in these males by covering the testicles with a lead shield. You might hear this called gonadal shielding or gonadal preservation. If radiation is aimed at one testicle (as for some testicular cancers), the other testicle should be shielded if possible. Some boys with leukemia need radiation directly to both testicles to destroy the cancer cells. Shielding is usually not possible for these patients.

The cost of radiation shielding is usually included in the cost of your treatments.

If you are getting radiation near your testicles, your cancer care team may also advise you to avoid unprotected sex (intercourse) and to not try to achieve a pregnancy for a certain length of time after treatment ends. If you are getting radiation to the pelvic or genital area, it's best to talk to your doctor about options, including sperm banking, if you wish to avoid the waiting period.

Options for men who are not fertile after cancer treatment

Use of donor sperm

Using donor sperm (also called donor insemination) is a way for men who are infertile after cancer treatment to become a parent. Major sperm banks in the United States collect sperm from volunteers who are young men and go through a detailed screening of their physical health, family health history, educational and emotional history, and even some genetic testing. Donors are also tested for sexually transmitted diseases, including HIV and hepatitis viruses. Couples may be able to choose a donor who will remain anonymous, one who provides personal information but does not want to make his identity known, or one who is willing to have contact with the child later in life.

The IUI procedures (see above) is usually done when donor sperm is used.

The cost of donor sperm and the IUI procedure varies. If you're interested in this approach, check with your insurance company about coverage and ask the fertility specialist what costs are involved with the process. Be sure to ask for a list of all fees and charges, since these differ from one center to another.

Adoption

Adoption is usually an option for many people who want to become a parent. Adoption can take place within your own country through a public agency or by a private arrangement, or internationally through private agencies. Foster care systems specialize in placing children with special needs, older children, or siblings.

Many adoption agencies or foster care systems state that they do not rule out cancer survivors as potential parents. But they may require you to be done with treatment, and likely will need some information about your type of cancer and quality of life. You may be able to find an agency that has experience working with cancer survivors.Cancer survivors have some legal protections (including against discrimination during adoption proceedings) under the Americans with Disabilities Act (ADA).

There’s a lot of paperwork to complete during the adoption process, and at times it can seem overwhelming. Many couples find it helpful to attend adoption or parenting classes before adopting. These classes can help you understand the adoption process and give you a chance to meet other couples in similar situations. The process takes different lengths of time depending on the type of adoption you choose.

Costs of adopting vary greatly, from around $6,000 (for a public agency, foster care, or special needs adoption) and $35,000 to $50,000 (for private U.S. and some international adoptions, including travel costs).

Child-free living

Many couples, with or without cancer, decide they prefer not to have children. Child-free living allows a couple to pursue other life goals, such as career, travel, or volunteering in ways that help others. If you are unsure about having children, talk with your spouse or partner. If you are having trouble agreeing on the future, talking with a counselor or mental health professional may help you both think more clearly about the issues and make the best decision.