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How to preserve fertility in men with cancer


Ideally, you should consult your doctor about the preservation of fertility before starting cancer treatment. Doctors do not always remember to address this issue, so it may be necessary for you to start the conversation about it.
Many types of chemotherapy and radiation therapy that involve the areas of the testicles or the pelvis can result in damage to the DNA of the sperm. This DNA damage can potentially cause the egg to not be fertilized or the pregnancies end in spontaneous abortions for the couple. If a child is conceived using sperm with damaged DNA, the genetic abnormalities of the sperm can be inherited by the child. These DNA changes can cause serious and even fatal abnormalities in the child.
It is very important that you ask your doctor if you can have unprotected sex during and after cancer treatment. Your team of doctors may recommend that you wait between 6 months to 2 years before trying to father a baby naturally or resume unprotected sex. It is best to talk with your team of doctors and your partner before you plan to try a pregnancy or resume sexual activity without protection. All of your treatment history will be taken into account, including chemotherapy drugs and doses administered, as well as where the radiation is going and the doses given.
Protection against radiation
Radiation therapy can cause infertility by permanently destroying the sperm-producing stem cells in the testicle. If it is necessary to administer radiation directly to both testicles, damage to the testicular tissue is inevitable. When radiation is directed to other structures in the pelvic area, X-rays can often disperse and thus cause indirect testicular injury. Fertility can sometimes be preserved in these men by covering the testicles with a lead shield. If radiation is directed to a testicle (as in the case of some testicular cancers), the other testicle should be protected, if possible. Some children with leukemia need radiation directly to both testicles to destroy the cancer cells. Protection is not possible for these patients.

If you are going to receive radiation near the testicles, there is often a risk of damaging the sperm due to X-ray scattering. Doctors often advise that men avoid unprotected sex and efforts to achieve pregnancy by 6 months after the termination of radiotherapy.
Patients receiving radiation therapy should consult with their cancer care team about the risks of infertility with radiation treatment and the length of time they will have to avoid unprotected sexual activity after therapy. For these reasons, patients should consider storing semen to avoid the waiting period and possibly increase the chances of successful conception later.
Bank of semen

The storage of semen is the best established method for the preservation of fertility in men. It consists of a fairly easy and effective way for men who start or have spent adolescence to store sperm for future use. Men who want to have children in the future are usually offered before cancer treatment, but sometimes doctors do not mention this option. If you know that you will probably want to father a child in the future, ask about it. Your doctor can refer you to a urologist specializing in reproductive health to proceed with the storage of semen, or the oncologist can make these preparations. You can do a search on the Internet to find yourself a semen bank.
Many men with cancer will have semen samples that indicate that the volume of ejaculation, the sperm count, the sperm motility or the percentage of sperm with normal form are low. This is a very common finding in men with cancer. It is important that patients know that they can and should store the semen even if they show a reduction in the quality or quantity of semen. The only requirement is that the sperm are alive. Often, children as young as 12 or 13 years old will be able to successfully store semen. If they have started puberty, there is a good chance that they are producing sperm and can produce a semen sample for freezing.
In the semen bank, the man provides one or more samples of his semen, ideally by ejaculation. Obtaining semen is usually done by masturbation in a private room in a semen storage center or hospital, although sometimes arrangements can be made for the patient to take a sample to the laboratory that he obtained at home. 
Semen must be received in the laboratory within one hour after ejaculation. The man ejaculates (has a sexual climax with the release of semen through the urethral orifice of the tip of his penis) by masturbation or with the help of a couple's stimulation. The semen is collected in a sterile container. In general, semen is not obtained during sexual activity (intercourse) because it could be contaminated with bacteria and vaginal discharge. For men with strict religious norms against masturbation, some banks facilitate the collection of semen during intercourse using a special silicone collector condom.
If a man faces difficulties to ejaculate, a vibratory stimulation device (vibrator) can be used. The difficulty to reach climax and ejaculation can occur in men who are not comfortable with masturbation, who suffer a lot of stress or anxiety, who take certain medications such as narcotic analgesics or antidepressants, and those with certain physical or anatomical changes in the penis that prevent normal sexual stimulation.
If you reside far from a laboratory or a semen bank, you could use a mailing kit. Some semen banks provide these kits to patients. The man collects his sample at home, mixes it with a special chemical protection substance and sends it by express courier to the semen bank immediately. Some sperm can die with the additional time required, so it is a better option to extract the sample and deliver it immediately to a laboratory.
Once the semen bank obtains the sample, it is analyzed to see how many sperm it contains (this is called sperm count), what percentage of sperm can swim (which is called motility) and what percentage has a normal shape (called morphology) ). The sperm are then frozen and stored.


The semen bank is an option for men who might want to have children after they finish cancer treatment, even if they are not sure that someday they want to father a child. Cancer patients can decide this issue later and leave the option available. If the samples are not used, they can be discarded or donated to carry out investigations.

Limitations to preserve semen

Rapidly growing cancers  if you have a rapidly growing cancer such as acute leukemia (acute myelogenous leukemia or acute lymphocytic leukemia), you may be too sick to produce semen samples before starting cancer treatment. If you can do it, having even a sample of stored semen could allow you to have a biological child in the future.

Infectious diseases:  Many semen banks do not accept samples from men who have HIV or hepatitis B, but some banks have special storage areas at a higher rate. The risks should be communicated to the woman who tries to get pregnant with the sperm of a man who has HIV or hepatitis B. The risk of infection for the woman can be reduced considerably by the use of advanced infertility treatments, provided there are expert doctors in the exhaustive use of risk reduction methods. If the woman is infected, there is a certain risk that the baby will also be infected.

Costs:  The average cost of storing sperm (about three samples) in a semen bank is approximately $ 1,500 to $ 2,500 for 3 years. There may be health insurance coverage, and storage costs vary widely, so it is important to compare the costs of different centers. Many semen banks offer financing and payment plans for people with cancer.

Other ways to get semen

Urine (for men with retrograde ejaculation)

Sometimes the nerves that are needed to ejaculate the semen or to close the valve at the entrance to the bladder are affected during surgery for cancer or radiation therapy. When this happens, it is possible that man continues to produce semen, but this may not leave the penis at the time of orgasm. Instead, the semen is expelled back into the bladder (retrogradeejaculation). This is not painful or harmful, although the urine may look cloudy, since the semen mixes with the urine.

Fertility specialists can often get sperm from the urine of these men and use it to achieve a pregnancy. Sometimes, these sperm can be placed in the uterus of the female partner at the time of ovulation by a small flexible tube called a catheter.

Electroejaculation

Ejaculation is a complex process that is necessary to expel the semen from the body. Some men will not be able to ejaculate due to stress, anxiety or other psychological causes. This situation is common in men newly diagnosed with cancer who are trying to store semen. In addition, some young adolescent males who may not have had any prior experience with masturbation may not be able to produce a semen sample. For these patients, electroejaculation can be used to stimulate the pelvic nerves that cause contraction of the epididymis, vas deferens, prostate, seminal vesicles and pelvic muscles that cause the release of semen. The electroejaculation procedure is performed while the patient is asleep under an anesthetic.

Several other conditions can also cause inability to ejaculate. First, men with a history of injury to the abdominal (belly) nerves or pelvic nerves may lose the ability to ejaculate. These nerve injuries commonly occur after surgery or radiation therapy in the belly (abdominal) or pelvic areas. The inability to ejaculate can also occur in men who take certain medications, such as narcotic painkillers and antidepressants. These drugs are used in many cancer patients and can negatively affect efforts to preserve fertility. Finally, some men will have swelling, inflammation, or other changes in the anatomy of the penis or pelvic tissues that interfere with the stimulation of the penis that is needed to cause ejaculation.

Few infertility clinics have the necessary equipment to carry out the electroejaculation. A tube is placed in the rectum and a low-voltage electric current is applied to stimulate ejaculation. The semen that is obtained by electroejaculation can be used immediately or it can be cryopreserved (frozen) for future use. One way or another, there are two options for the final use of sperm. Sperm can be used in intrauterine insemination (IUI, for its acronym in English, are placed in the uterus through a catheter at the time of ovulation) or in vitrofertilization (IVF, the mature ovules are extracted from a woman's ovaries and attached to sperm in a laboratory to develop embryos, which are then transferred to the uterus of the female partner).

Sperm extraction and aspiration procedures

These procedures are options for collecting sperm in men who do not have sperm in their semen, either before or after cancer treatments. Both require a urologist to perform minor surgery.

  • In percutaneous epididymal sperm aspiration (PESA) , a needle is inserted through the skin of the scrotum and into the epididymis (spiral tubes found on the upper part of the testicle). Suction is applied to the needle and sperm are sucked through the needle.
  • In a procedure of microsurgical sperm aspiration of the epididymis (MESA) , a small incision is made in the skin of the scrotum, and a microscope is used to extract the sperm from the epididymis under microscopic vision. Extraction of sperm from the epididymis is usually only performed when sperm production is normal and there is an obstruction in the semen release system.
  • In the extraction of testicular sperm (TESE) , a small incision is made in the skin of the scrotum, and tiny fragments of testicular tissue are removed to examine them and know if they contain sperm.
  • The procedure called micro-TESE is similar, except that a surgical microscope is used to examine and help select the areas of testicular tissue that are removed. 

The TESE and Micro TESE procedures are commonly performed in both men with normal and decreased semen production. This contrasts with the extraction of sperm from the epididymis, which is usually only performed when sperm production is normal, but the semen release system is blocked.

With the extraction of sperm from the epididymis and the extraction of sperm from the testicle, if mature sperm are found, these can be used immediately (for IVF-ICSI, described above) or they can be frozen for future use.

Successful results in the use of frozen sperm

The success rates of treatments for infertility with frozen sperm vary and depend on the quality of the sperm after thawing, as well as the health and age of the female partner. In general, sperm that are obtained before cancer treatment are just as likely to start a pregnancy as sperm from men who do not have cancer. The conservation of semen in banks has resulted in thousands of pregnancies, without unusual rates of congenital defects or health problems in children. Once the sperm is stored, it remains in good condition for decades. The semen banks became much more practical and successful in the 1990s,

Keep in touch with your semen bank

It is important to keep in touch with the semen bank to be up to date in the payment of annual storage fees and keep your mailing address updated. Once the couple is ready to have a child, the frozen sperm is sent to their fertility specialist. Some semen banks will destroy and discard semen samples when patients lose contact with them.

The use of semen for intrauterine insemination

If the thawed semen sample contains at least 5 to 10 million motile sperm (actively swimming), it could be used for intrauterine insemination. The thawed sperm are washed and concentrated, and then placed in a sterile solution called medium. When the woman is at her most fertile moment of the month, this liquid is introduced into her uterus by a tiny tube (called a catheter) inserted through the vagina, into the small opening of her cervix, passing to the uterus.

In general, this procedure takes only a few minutes and is done in the obstetrician / gynecologist's office. Sometimes a woman takes hormones to mature more than one egg before the sperm is placed in her uterus to increase the likelihood of pregnancy. This is called superovulation.

Use of sperm for in vitro fertilization (IVF) and in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI)

In in vitro fertilization (IVF), after the eggs are removed from the woman, each one is cleaned and placed in a sterile container with several thousand sperm. The goal is for one of the sperm to fertilize the egg. This process often works well when the sperm have good motility (actively swim). However, they can sometimes have little mobility after freezing and thawing. Currently, it is more common to solve this problem and increase the chances of successful fertilization by injecting a sperm into each ovule. This procedure is called IVF-ICSI, which means in vitro fertilization withintracytoplasmic sperm injection. It is sometimes referred to as ICSI. With ICSI, a viable sperm is injected directly into an egg to fertilize it, resulting in an embryo that can then be transferred to the uterus of the female partner to achieve a pregnancy.

In both IVF and IVF-ICSI, the female partner receives injections of hormones for 2 to 3 weeks to induce the production of multiple mature ovules. These ovules are then removed from the ovary in a minor procedure performed in the doctor's office. In the laboratory, a healthy-looking live sperm is injected into each ovule. Each injected ovum is observed thoroughly to determine if fertilization has occurred and if normal and early embryo development occurs. The embryos can be placed back in the woman's uterus during that cycle or they can be frozen for future use.

Many cancer survivors have sperm in the semen after treatment, but sperm counts and motility are low. If there are no semen samples stored in a bank, IVF-ICSI can be a good way to manage these changes in the sperm of cancer survivors. As mentioned above, most doctors will recommend that couples wait 1 to 2 years after the termination of cancer treatment before attempting to achieve a pregnancy with ejaculated sperm due to the possibility of DNA damage from them.

Options for men who are not fertile after cancer treatment

Use of donor sperm

A simple and inexpensive way for men who are infertile after cancer treatment to become parents is to use a donor's sperm (also called donor insemination). Major semen banks in the United States obtain semen from young men who have undergone comprehensive physical health screening tests, family medical history, educational and emotional background and even some genetic tests. Donors are also tested for sexually transmitted diseases, including HIV (the virus that causes AIDS) and hepatitis B and C viruses. Couples can choose a donor who will remain anonymous (provides personal information, but not wants to make his identity known), or one who is willing to have contact with the child in the future.

Intrauterine insemination with donor sperm is done by an obstetrician / gynecologist in your office. The donor sperm can be placed in the uterus of the female partner at the time of ovulation through a small flexible tube called a catheter. If necessary, a woman's doctor can prescribe hormones to mature and release more than one egg, which will increase the chances of fertilization and pregnancy. As mentioned above, IUI pregnancy rates usually range from 5% to 15% for each attempt when the female partner is healthy. Couples commonly try with the IUI method 3 to 4 times.

The cost of donated semen varies, but on average it costs approximately $ 700 per sample, which does not include the cost of insemination or the cost of hormones when used for women. Be sure to request a list of all fees and costs since they vary from one semen bank to another.

Adoption

In general, adoption is an option for anyone who wants to become a father. Adoption can be carried out in your own country through a public agency, through a particular arrangement or internationally through private agencies. Foster homes systems specialize in locating children with special needs, older children or siblings.

Most adoption agencies or foster care systems claim that they do not exclude cancer survivors as potential parents. However, they usually require a letter from your doctor stating that you do not have cancer now and that you can have a healthy life span and a good quality of life. Some agencies or countries require that a period without treatment and cancer have passed before a cancer survivor can apply for adoption. The average time period is usually 5 years. Unfortunately, only a handful of countries allow international adoption to cancer survivors.

During the adoption process, many documents have to be completed and sometimes this may seem overwhelming. Many couples find it helpful to attend adoption or parenting classes before adoption. These classes can help you understand the adoption process and give you the opportunity to meet other couples who are in similar situations. The process takes different periods of time depending on the type of adoption you choose.

The costs of adopting vary widely, from less than $ 4,000 (for a public agency, foster care or adoption of children with special needs) to $ 50,000 (for some international adoptions, including travel expenses).

You can find an agency that has experience with cancer survivors. Clearly, there is some discrimination in both national and international adoption. However, most cancer survivors who want to adopt can do so. Cancer survivors have legal protections (including protection against discrimination during the adoption process) granted by the Americans with Disabilities Act (ADA).

A life without children

Many couples, with or without cancer, decide that they prefer not to have children. Life without children allows the couple to seek other goals in life, such as a profession, travel or volunteer to help others. Talk to your spouse or partner if you are unsure about having children. If you are having difficulty making decisions about the future, consulting with a mental health professional can help both of you think more clearly about these issues and make the best decision.
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