Sperm Freezing for Cancer Patients Undergoing Chemotherapy

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No matter who you are, a cancer diagnosis can be overwhelming. It is a life-changing, monumental moment that can turn your world upside down. It is normal to feel as if your life has completely spun out of control. The initial shock will fade, but the challenges – physical, emotional, and spiritual – that lay ahead can be just as overwhelming. This guide offers tips to develop a strategy to cope and manage with the illness, as well as answering common questions especially as relating to reproductive health.


First Steps

I’ve just been diagnosed with cancer. What should I do?

The emotional shock of a cancer diagnosis is a lot to handle. Our natural instinct is to react and take immediate action. However, it’s important to take a moment to process the information you’ve just been told – then, you’ll be able to figure out your next steps.


1. Ask your doctor how much time you have before making the decision to start treatment.

Don’t rush into treatment. Although sometimes it is necessary to start treatment as soon as possible, often it is not. In most cases, you’ll have time to think about where and when you go in for treatment. Take your time to think about a plan that’s appropriate for you, finding a team that you’re comfortable with, and evaluate different treatment options.

2. Educate yourself.

Knowledge is power – studies have shown that patients who are more informed about their illness tend to handle side effects better than those who blindly follow doctor’s instructions. Being informed gives you measure of control over the situation, giving you a sense of empowerment that is beneficial to the healing process. Get organized – bring a binder or notebook to your appointments and collect any information pertaining to your case. Ask lots of questions, but at a pace you feel comfortable with.

3. Establish a strong support system.

No one should go through a fight against cancer alone. Cancer treatment is a very emotionally taxing process – having someone you can talk openly with about serious issues will make the process that much easier. Bring someone with you to your appointments – your care team may share a lot of information, and it helps to have someone there to help remember it all and talk it through after your appointments.

4. Get a second opinion.

Cancer is a complicated disease, and different doctors may choose to tackle it with different approaches. As a patient, you have a right to a second opinion, or even a third – it can help you better understand your situation and provide a sense of control. Some insurance companies will even require a second opinion.

5. Ask for help.

A cancer diagnosis is daunting and can raise personal issues such as anxiety or depression. These feelings are normal. You can connect with other cancer patients, survivors, and caregivers that have been through the process. If you need to, don’t be afraid to seek professional help to deal with your emotions.

6. Be your own advocate.

Take an active role in your medical decisions. You form a key part of the team that treats you. If something doesn’t seem right, speak up. If you’re not comfortable with the decisions being made, or if your doctor is unwilling to listen to your concerns, find someone that will work with you.

7. Treat yourself right.

Eat well, exercise, and get good sleep as well as you can. These things are within your control, giving you a sense of empowerment and preparing your body to be as healthy as it can be.

8. Get to know your insurance.

Although the cost of many standard cancer treatments has declined, some can still be incredibly expensive. Know the ins and outs of your insurance plan – if possible, talk to a social worker or financial planner with experience in the process that can walk you through how much of your treatment will be covered under your plan. There are many co-pays, deductibles, and co-insurance costs that you may have to pay out of pocket. Find out what doctors or hospitals are in your network.

9. Ask about new treatments or clinical trials that may be right for you.

Clinical trials can be explored very early on in treatment, and there’s trials for virtually every type of cancer currently ongoing. The decision to enter a trial may be complicated, but it’s worth discussing with your doctor.

10. Figure out your options for the future – especially if you want to start a family.

Dealing with cancer can be an overwhelming experience, and it is often a good idea to take life one day at a time. However, the odds of beating cancer are better than ever. For example, the five-year survival rate for prostate cancer is 99%. Nonetheless, the side effects of cancer treatment can affect your fertility and your capability of fathering children. That’s why it’s important to consider all the options, including fertility preservation treatments. Simple interventions such as sperm freezing are increasingly common, and companies such as Legacy make this process easy and accessible.

 

 

The rest of this guide will go into detail of how cancer can affect your fertility and what you can do about it.

 

What types of cancer can directly cause male infertility?

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Hodgkin’s disease, lymphoma, or leukemia – About 40% of men with Hodgkin’s disease will have low sperm counts at the time of diagnosis. These types of cancers are systemic, which means they affect the whole body. Thus, they can also disrupt the normal functioning of our reproductive processes and lower the quality of sperm.

Testicular cancer – About 50% of men with testicular cancer will have low sperm counts at the time of diagnosis. This type of cancer will interrupt the normal processes of spermatogenesis, leading to less and lower quality sperm. Even though only 1-3% of men will get cancer on both testicles, the cancer free testicle may not work normally.

Prostate cancer – This type of cancer can damage both the prostate gland and the seminal vesicles, both of which are involved in the production of sperm and semen. However, it is typically the treatment for this type of cancer that can lead to infertility issues.


What types of treatment can cause male infertility?

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Radiation Therapy – Radiation therapy uses high-energy x-rays to kill cancer cells. Radiation causes small breaks in a cell’s DNA. In normal cells, the damage is typically repaired, and the cell survives. However, cancerous cells grow and divide so quickly that they can’t repair the damage, which accumulates and eventually kills them. Radiation is normally a localized treatment, unlike chemotherapy which affects the whole body. Radiation therapy is often one of the preferred methods of treatment, as side-effects are typically not as severe and it can be very effective for some types of cancer. 

However, radiation therapy carries its own risks. The use of radiation may slightly increase the risk of getting another cancer, although the benefit of treating a current cancer far outweighs that risk. Side effects may also vary depending on where the radiation is given. Total body irradiation(TBI - used for bone marrow transplants, among others) can be very damaging to fertility – almost 80% of men who get TBI will have permanent sterility after treatment. Radiation to the midsection (such as the abdomen or pelvis) can also lead to fertility issues, although sometimes the testicles can be shielded to protect from damage. Radiation directly to the testicles or the pituitary gland (which controls many aspects of hormone release) will also damage fertility.

Chemotherapy – Chemotherapy works by targeting cells in the body that divide quickly. Since cancerous cells divide much faster than many other cells in the body, they are disrupted and killed by chemotherapy. However, other cells in the body such as hair follicles, those lining the gut, and germ cells (reproductive cells such as sperm and eggs) are also fast-dividing and can be significantly affected. This is why common side effects of chemotherapy include hair loss, gastrointestinal issues, mouth sores, and lower fertility. Sperm cells are an easy target for chemotherapy – infertility issues arise when immature cells in the testicles that divide to make sperm are damaged to the point where they can no longer divide and produce mature sperm cells.

Nonetheless, not all chemotherapy drugs are created equal. The type and dosage of chemo drugs received will determine the extent of damage to fertility. After treatment, sperm production may slow down or stop altogether. A group of chemo drugs called alkylating agents are the most harmful to fertility. Some notable examples are Busulfan, Carmustine, Cyclophosphamide, and Lomustine, among many others. Speak with your doctor about the potential risks to fertility that your chemotherapy treatment may entail.

Surgery – Surgery can be an extremely effective form of treatment for many types of cancer, especially if they remain localized and haven’t spread to other parts of the body. Although surgery is one of the less likely treatments to affect fertility, it is highly dependent on the area the surgery is done. Surgery for testicular cancer will impede normal sperm production – if both testicles are removed, sperm production halts entirely. Surgery near the abdomen, the prostate, or the bladder, among others, will also affect fertility by affecting the ability to produce sperm or ejaculate.


What are the possible outcomes on my fertility after treatment?

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Not all cancer treatments can cause infertility, and there is a lot of room for variation among those that do. Factors that can influence your fertility after treatment include:

  • Your fertility before starting treatment

  • Your age (men over 40 may have a harder time recuperating fertility)

  • Type of cancer that is being treated

  • Treatment option being used

    • Chemotherapy – Type and dose of chemotherapy utilized

    • Radiation – Affected area and dose utilized

    • Surgery – Location and extent of surgery


After treatment, your fertility may fall in 1 of 4 categories:

Normal Fertility – Normal sperm count and function are preserved. Often, one can try to conceive shortly after treatment (generally at least 6 months). 

Compromised Fertility – Normal sperm count and function may be significantly disrupted. Damage to nerves and channels used to transport sperm, disrupted hormone production, or impaired sperm production are common causes. Conceiving naturally may be hard and require medical assistance and technologies. 

Temporary Infertility – Sperm production may stop for a period of time, meaning you do not find sperm in ejaculate. Normal fertility may be restored immediately or several years after treatment ends. Generally, sperm production is restored within 1-4 years. If production has not recovered at all after 4 years, it is less likely to return. 

Permanent Sterility – Sperm viability is irreversibly compromised. No sperm will be found in ejaculate. Nonetheless, some sperm may still be found in the testicles, which may still be utilized with the help of medical technologies.


What are my options to preserve fertility?

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Sperm Banking – Known as cryopreservation, this process involves the freezing and storage of sperm. This is the most efficient, convenient, and accessible method for fertility preservation in men. Once frozen, the sperm can be stored for years and later utilized for IVF (In-Vitro Fertilization), IUI (intra-uterine insemination) or ICSI (Intra-cytoplasmic sperm injection). 

Sperm banking is recommended before the start of therapy, as there is a higher risk of damage to the sperm’s DNA once treatment begins. Although sperm can be collected after treatment has started, it is not recommended as there is no data on the risks involved to the fetus. 

Sperm banking has traditionally been done in clinics, where the sperm is collected in person. However, this process can be awkward and inconvenient, to say the least. Nonetheless, other options have recently become viable – Legacy provides men with a collection kit that allows the process to be done from the comfort of your own home. Collected sperm is kept safe in a specialized medium which allows it to be shipped directly to the lab for further analysis and storage. 


Testicular Sperm Extraction – This option is suitable for men who cannot produce sperm in ejaculate – be it due to a vasectomy, blockage, or other – but are still producing sperm in their testicles. This process involves the extraction of sperm directly from the testicles, using a small needle and syringe. It’s minimally invasive and typically recovery takes only a few days. Sometimes, some testicular tissue has to be removed and examined for sperm.


Alternative Options:

Testicular Tissue Freezing – This option is aimed towards boys who undergo treatment before reaching puberty. This procedure involves removing and freezing testicular tissue, which can be used at a later date in a couple ways. One method is collecting sperm stem cells from the tissue and then implanting those cells back into the testicles with the aim of restoring normal function. Another method involves implanting the tissue back into the testicle or elsewhere on the body after treatment, and then waiting for puberty so that the intact tissue starts making sperm again. 

This option is still in its infancy – lots of research remains to be done before it can be used effectively. The technique has been utilized successfully in animals, but there are still no recorded births in humans using this method.


Will my insurance cover these treatments?

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Cancer treatment can impose a heavy financial burden, and you may be wondering if any of these fertility preservation treatments are covered by insurance. Unfortunately, many of the newer procedures are still considered experimental or niche and will not be covered by insurance. Some fertility protection methods, such as testicular shielding for radiation treatment, is covered since it is considered a standard part of the treatment. 

Sometimes, normal infertility coverage could be applied to fertility preservation, yet cancer patients may face a unique challenge. Infertility is defined as a lack of conception after a year of regular unprotected sex. However, many cancer patients will not meet the criteria for infertility at the time of their diagnosis – they know their fertility may be at risk from treatment, but they are not covered for fertility preservation at the time when it is most necessary.   

Patients can petition their insurance company for coverage, although it is rarely successful. Patients can ask their oncologist or fertility specialist to explain to your insurer why fertility preservation methods are deemed medically necessary, and can sometimes receive post-treatment reimbursement. 

Furthermore, some fertility preservation options can be quite pricey. Standard cryopreservation clinics will often many hundreds of dollars to store only a few vials of sperm per year. Newer options such as Legacy aim to lower the cost of storage and analysis whilst maintaining medical-grade quality.


Post-Treatment

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How long should I wait before trying to father a child?

Oftentimes, the type of treatment you get can have deleterious effects on the quality of your sperm. Generally, if you were treated with radiation or chemotherapy (or a combination of both), you should wait at least a year before trying to conceive. This gives your body time to clear any damaged sperm from your system. However, this is dependent on the length and intensity of your treatment – you may not need to wait as long. Ask your doctor how long they recommend waiting before attempting to conceive. 

Is there a risk that cancer treatment could influence the health of my future child?

During treatment, your sperm run a much higher risk of genetic damage. It’s important to use birth control during treatment so that you do not conceive with damaged sperm from chemotherapy or radiation. It’s also recommended to use some form of birth control for a least a year after your treatment. 

However, there is NO evidence that children conceived after cancer treatment are at a higher risk of birth defects or other medical problems. 

Nonetheless, some cancers have a strong hereditary component, which means they may be passed down to your children. Ask your doctor if your cancer may be hereditary – if so, you can meet with a genetic counselor to explain the risks and how it may affect your child. 

There are options to explore in the case your cancer is hereditary. For example, preimplantation genetic testing (PGT) allows you to test embryos that have been conceived through IVF for a specific mutation related to your cancer. You can then screen for embryos that don’t have the mutation when you’re ready for implantation.

What do I do if I am no longer fertile?

If you banked your sperm:

If you banked your sperm before treatment, there are several options available to conceive. The method used will depend on the quantity and quality of your banked sperm.

In-Vitro Fertilization (IVF): The most often used method to utilize banked sperm. This procedure involves the collection of eggs from your female partner, which are later fertilized with the now thawed sperm. If your sperm count is very low, a procedure known as Intra-cytoplasmic sperm implantation (ICSI) may be utilized, in which the sperm is injected directly into the egg. Once fertilized, the eggs are kept under observation for a few days to ensure they will form healthy embryos. An embryo or two is then selected for implantation into your partner’s uterus, while the rest are frozen and stored. 

Intra-Uterine Insemination (IUI): Also known as artificial insemination, this method can be utilized if you have a lot of high-quality banked sperm – typically at least 7 or 8 vials worth. With IUI, one or 2 vials of sperm are thawed and then drawn up into a thin catheter. The catheter is then positioned in your partner’s uterus and the sperm are released. This procedure is done around the time of ovulation to maximize the chances of fertilization. 

Even so, IUI is not always successful, and it may take several attempts before viable fertilization. This is why it is only recommended for patients with several vials of banked sperm, and if your female partner has no fertility issues.  

If you don’t have banked sperm:

If you don’t have any banked sperm, there are still a few newer methods that may allow for conception. Some of these are still experimental, such as testicular tissue freezing and stem cell therapy, and may not be offered. 

Testicular Sperm Extraction (TESE): Even when no sperm can be found in the ejaculate, sometimes small amounts of sperm are still being produced in the testicles. A small surgery is performed in which small pieces of testicular tissue are removed and examined for sperm. The surgery is minor and considered an outpatient procedure. 

If none of these methods are appropriate for you, other alternatives such as utilizing a sperm donor or adoption may be considered.