Onco-fertility & fertility preservation

Why this matters, and why it is urgent

Chemotherapy, radiotherapy and some cancer surgery can damage sperm production, sometimes permanently. Survival rates for the cancers most likely to affect younger men — testicular cancer, lymphoma, leukaemia — are now high, which means large numbers of men live for decades after treatment and are affected by decisions made in the days before it started.

Fertility preservation is time-critical. Once chemotherapy begins, the quality of any sperm stored falls, and the window can close quickly. If you have been diagnosed with cancer and children may matter to you at any point in the future, this conversation needs to happen now — not after treatment.

Sperm banking before treatment

For most men, the simplest and most effective option is freezing ejaculated semen before treatment starts. Ideally two or three samples are collected, though a single sample is much better than none. Samples can be stored for many years and used later for insemination, IVF or ICSI.

Cancer itself — particularly testicular cancer and lymphoma — can already have reduced sperm quality at diagnosis, so results may be lower than expected. This is not a reason to skip banking. Even poor-quality samples can be used successfully with ICSI, where only a handful of sperm are needed.

When ejaculated sperm cannot be obtained

Some men cannot produce a sample — because they are too unwell, because of the stress of a new cancer diagnosis, because they are too young, or because there are no sperm in the ejaculate. Surgical options exist:

• Surgical sperm retrieval at the time of another planned procedure
• Onco-TESE — sperm retrieval performed at the same time as removal of a cancerous testicle, taking tissue from the healthy testis or from unaffected areas of the diseased one
• OncomicroTESE — microsurgical retrieval in men who have azoospermia in the context of cancer, including men who have already started or completed chemotherapy. Performed under the operating microscope in the same way as microTESE
• Electroejaculation in selected men unable to ejaculate

After cancer treatment

Sperm production can recover after chemotherapy, sometimes taking two to five years, and occasionally longer. It does not always recover, and the likelihood depends on the drugs used, the cumulative dose, and whether radiotherapy involved the pelvis or testes.

If you did not bank sperm before treatment, do not assume nothing can be done. Assessment after recovery, repeated over time, may find sperm returning. Where it does not, oncomicroTESE can still find sperm in a proportion of men. I see men years after cancer treatment who were told at the time that their fertility was gone and never re-tested.

Testicular cancer specifically

Men with testicular cancer often have impaired semen quality even before treatment, and removal of one testicle further reduces reserve. Sperm banking before orchidectomy, or onco-TESE at the time of surgery, should be offered routinely. Testosterone levels also need monitoring afterwards, since some men develop deficiency, which affects energy, mood, bone health and sexual function as well as fertility.

Working with your oncology team

Fertility preservation should never delay urgent cancer treatment, and in practice it rarely needs to. I work directly with oncology, haematology and fertility teams to arrange assessment and storage within whatever window exists, including at very short notice. Where surgery is needed, it can often be coordinated with procedures you are already scheduled for.

My practice

I established the largest male infertility service from south of the Thames to the south coast at Guy's Hospital in 2012, specialising in microsurgery and onco-fertility — fertility preservation in cancer patients. With Julia Kopeika I set up one of the few joint fertility clinics within the Guy's Assisted Conception Unit, one of the largest fertility units in the UK, managing complex cases. I am the author of three chapters in the BMA award-winning book Problem Solving in Cancer & Fertility.