Preserving Fertility in Men with Cancer

Ideally, discussions about preserving fertility should take place before cancer treatments begin.  Doctors don’t always remember to bring this up, so you might have to bring it up yourself.

Many types of chemotherapy and radiation therapy involving the testicles and/or pelvic areas can result in sperm DNA damage. This DNA damage can potentially cause failure to fertilize the egg or pregnancies that end in miscarriage for the couple.  If a child is conceived using sperm with damaged DNA, the sperm genetic abnormalities can be inherited by the child.  These DNA changes can result in serious and even life-threatening abnormalities in that child.

It is very important to discuss with your doctor if you can have unprotected sex both during and after cancer treatment. Your medical team may recommend waiting anywhere from 6 months to 2 years before trying to have a child by natural means or resuming unprotected sexual intercourse. It’s best to have this discussion with your medical team and with your partner before  planning attempts to achieve a pregnancy or resuming unprotected sexual activity.  Your treatment history, including chemotherapy drugs and dosages administered and radiation location and dosages given, will all be considered.

Radiation shielding

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. 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 not possible for these patients.

If you are getting radiation near your testicles, there is often a risk of damaging the sperm due to x-ray scatter. Doctors often advise men to avoid unprotected intercourse and efforts to achieve a pregnancy for 6 months after completion of radiation treatment.

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. For these reasons, patients should consider sperm banking to avoid the waiting period and also to possibly raise the odds of successful conception later on.

Sperm banking

Sperm banking is the most well established method of fertility preservation for men. It’s a fairly easy and successful way for men who have entered adolescence 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.  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 doctor might arrange it himself or herself. You might be able to find a sperm bank yourself with an online search.

Many males with cancer will have semen samples showing that the ejaculate volume, sperm count, sperm motility, or percentage of sperm with normal shape is low.  This is a very common finding in males with cancer. It is important for patients to know that they can and should store the sperm even if they have reduced sperm quality or quantity. The only requirement is that the sperm be alive. Boys as young as 12 or 13 years old will often be able to successfully bank sperm.  If they have started puberty, there is a good chance that they are making sperm and can produce a semen sample for freezing.

In sperm banking, a male provides one or more samples of his semen, ideally by ejaculating. Semen collection is usually done by masturbation in a private room at a sperm bank facility or hospital, although sometimes arrangements can be made for the patient to bring a sample that he collected at home into the lab. 

The sperm needs to be received in the lab within one hour after ejaculation. The man ejaculates (has a sexual climax with the release of semen from the urethral opening at the tip of his penis) through masturbation or with the help of stimulation from a partner. The semen is collected in a sterile cup. Sperm is not usually collected during intercourse because it could be contaminated with bacteria and vaginal fluid. For men with strong religious rules against masturbation, some banks facilitate semen collection during intercourse using a special silicone collection condom.

A vibratory stimulation device (“vibrator”) can be used to help to a man ejaculate if he is having difficulty. Difficulty reaching climax and ejaculation can occur in a patient who is not comfortable with masturbation, in males with a lot of stress or anxiety, in males on certain medications such as narcotic pain medications or antidepressants, and in males with certain physical or anatomical changes to the penis prevent normal sexual stimulation.

If you live far from any lab or sperm bank, you might be able to use a mail-in kit. Some sperm banks provide these kits to patients. The man collects his sample at home, mixes it with a special protective chemical, and express mails it to the sperm bank right away. Some sperm may die with this increased time requirement, so if you can collect a sample and immediately deliver it to a lab, it is a better option.

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.

Sperm banking is an option for males who might want to have children after completing cancer treatment, even if they aren’t sure that they will one day want to father a child. By storing sperm, male cancer patients can decide this issue later and leave their options open. If the samples are not used, they can be discarded or donated for research.

Limitations to sperm banking

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.     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 or hepatitis B, but some do have special storage areas for a higher storage fee. A woman who tries to get pregnant with sperm from a man who has HIV or hepatitis B must be told about the risks. The infection risk to the woman can be greatly lowered by using advanced infertility treatments, as long as there are expert doctors using careful risk reduction methods. If the woman becomes infected, there’s some risk that the baby can become infected, too.

Costs: The average cost of storing sperm (about 3 samples) in a sperm bank is about $1500-2500 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.

Other ways to collect sperm

From the urine (for males with retrograde ejaculation)

Sometimes the 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). This is not painful or harmful, though the urine may look cloudy afterward because there’s semen in it.

Fertility specialists are often able 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.

Electroejaculation

Ejaculation is a complex process that is necessary for the release of sperm from the body. Some males will be unable to ejaculate due to stress, anxiety, or other psychological causes. This situation is common in males newly diagnosed with cancer who are trying to bank sperm.  Additionally, some young adolescent males who may have had no prior experience with masturbation might not be able to produce a semen sample. For these patients, electroejaculation can be used to successfully stimulate the pelvic nerves that cause contraction of the epididymis, vas deferens, prostate gland, seminal vesicles, and pelvic muscles that cause the release of sperm. The electroejaculation procedure is done with the patient asleep under an anesthetic.

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

Small numbers of infertility clinics have the equipment necessary to perform electroejaculation.. A probe is put into the rectum and a low voltage electrical current is used to stimulate ejaculation. The semen that is collected by electroejaculation can either be used immediately or cryopreserved for future use.  Either way, two options exist for ultimate use of the sperm.  It can be used in IUI (where the sperm is delivered into the uterus through a catheter at the time of ovulation) or IVF (where mature eggs are removed from a woman’s ovaries and joined with the sperm in the lab to create embryos, which are then transferred into the female partner’s uterus).

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. Both require minor surgery performed by a urologist.

  • In percutaneous epididymal sperm aspiration (PESA), a needle is inserted through the scrotal skin and into the epididymis (the coiled tubes that sit on top of the testicle).  Suction is applied to the needle, and sperm are aspirated out through the needle.
  • In a microsurgical epididymal sperm aspiration (MESA) procedure, a small incision is made in the scrotal skin, and an operating microscope is used to remove sperm from the epididymis under microscopic vision. Sperm extraction from the epididymis is typically only performed when sperm production is normal and a blockage exists within the sperm delivery system.
  • In testicular sperm extraction (TESE), a small incision is made in the scrotal skin, and tiny pieces of testicular tissue are removed inspected for sperm cells.
  • A micro-TESE procedure is similar, except an operating microscope is used to inspect and help select the areas of testicular tissue that are removed. 

TESE and Micro-TESE procedures are commonly done on men with either normal or decreased sperm production.  This contrasts with sperm extraction from the epididymis, which is typically only performed when sperm production is normal but the sperm delivery system is blocked.

With both epididymal and testicular sperm extraction techniques, if mature sperm are found, they can be used right away (for IVF-ICSI, described above) or frozen for future use.

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 partner. In general, sperm collected before cancer treatment is just as likely to start a pregnancy as sperm from men without cancer. Sperm banking has resulted in thousands of pregnancies, without unusual rates of birth defects or health problems in the children. Once sperm is stored, it’s good for decades. Sperm banking became much more practical and successful in the early 1990s, when IVF clinics started using a procedure called intracytoplasmic sperm injection (ICSI) (see below).

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. Once a couple is ready to have a child, the frozen sperm is sent to their fertility specialist. Some sperm banks will destroy and discard sperm samples when patients lose touch with them.

Using sperm for intrauterine insemination (IUI)

If the thawed sperm sample contains at least 5-10 million motile (actively swimming) sperm, it can potentially be used for IUI. The thawed sperm are washed and concentrated, and then they are place in a sterile solution called media. When the woman is at her most fertile time of the month, this fluid is introduced into her uterus by inserting a tiny tube called a catheter through her vagina, into the small opening in her cervix, and up into the uterus.

This procedure usually just takes a few minutes and is performed in an obstetrician/gynecologist doctor’s office. Sometimes the woman takes hormones to mature more than 1 egg before the sperm is placed in her uterus to increase the chance of pregnancy. This is called superovulation.

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

With IVF, after eggs are retrieved from the woman, each is cleaned and placed in a sterile dish with several thousand sperm.  The goal is for one of the sperm to then fertilize the egg. This often works well when the sperm cells have good motility (swimming power). After freezing and thawing, however, motility can sometimes be low. Currently, it is more common to inject a sperm into each egg, getting around that problem and increasing the odds of successful fertilization. This procedure is called IVF-ICSI, which stands for in vitro fertilization with intracytoplasmic sperm injection. Sometimes it’s just called ICSI. With ICSI, a single viable sperm is injected directly into an egg to fertilize it, resulting in an embryo that can then be transferred back into the female partner's uterus to achieve a pregnancy.

In both IVF and IVF-ICSI, the female partner takes hormone shots for 2-3 weeks to lead to the production of multiple mature eggs. These eggs are then removed from the ovary in a minor office procedure. In the lab, one healthy-looking, living sperm is then injected into each egg. Each injected egg is observed closely to determine if fertilization has occurred and if normal early embryo development occurs.. The embryos that result can either be put back into the woman’s uterus during that cycle or frozen for future use.

Many cancer survivors have sperm in the ejaculate after treatment, but sperm counts and motility are low. If there are no banked sperm samples, IVF-ICSI can be a good way to deal with these sperm changes in cancer survivors. As mentioned above, most doctors will recommend that couples wait 1-2 years after the completion of cancer treatment before trying to achieve a pregnancy using ejaculated sperm due to the possibility of sperm DNA damage.

Options for men who are not fertile after cancer treatment

Use of donor sperm

Using donor sperm (also called donor insemination) is an inexpensive and simple way for men who are infertile after cancer treatment to become a parent. Major sperm banks in the United States collect sperm from young men who 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 (the virus that causes AIDS) and the hepatitis B and C 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.

IUI with donor sperm is done by an obstetrician/gynecologist doctor in his or her office. The donor sperm are placed into the female partner’s uterus at the time of ovulation using a small flexible tube called a catheter. If needed, the woman’s doctor might prescribe hormones to cause more than one egg to mature and be released, which will increase the chances of fertilization and a pregnancy. As mentioned above, pregnancy rates for IUI typically range from 5%-15% per attempt when the female partner is healthy. Couples will commonly try the IUI approach up to 3 to 4 times.

The cost of donor sperm varies, but averages about $700 a sample, which does not include the cost of the insemination or the cost of hormones when they are used for the female. Be sure to ask for a list of all fees and charges, since these differ from one center to another (see Frequently Asked Questions About Fertility and Cancer ).

Adoption

Adoption is usually an option for anyone who wants 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.

Most adoption agencies or foster care systems state that they do not rule out cancer survivors as potential parents. But they often require a letter from your doctor stating that you are cancer-free and can expect a healthy lifespan and a good quality of life. Some agencies or countries require a period of being off treatment and cancer-free before a cancer survivor can apply for adoption. Five years seems to be an average length of time. Unfortunately, only a handful of countries allow cancer survivors to adopt internationally.

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 less than $4,000 (for a public agency, foster care, or special needs adoption) up to $50,000 (for some international adoptions, including travel costs).

You may be able to find an agency that has experience working with cancer survivors. Some discrimination clearly does occur both in domestic and international adoption. Yet, most cancer survivors who want to adopt can do so. Cancer survivors have legal protections (including against discrimination during adoption proceedings) under the Americans with Disabilities Act (ADA).

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 mental health professional may help you both think more clearly about the issues and make the best decision.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

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Last Medical Review: November 6, 2016 Last Revised: June 28, 2017

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