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Sperm Banking and Assisted Reproduction Treatment for Couples Following Cancer Treatment of the Male Partner

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Sperm Banking and Assisted Reproduction Treatment for Couples Following Cancer Treatment of the Male Partner Human Reproduction Update, Vol.7, No.4 pp. 370±377, 2001 Sperm banking and assisted reproduction treatment for couples following cancer treatment of the male partner Amir Lass1, Fidelis Akagbosu and Peter Brinsden Bourn Hall Clinic, Bourn, Cambridge CB3 7TR, UK 1To whom correspondence should be addressed at: Serono Pharmaceuticals Ltd., Bedfont Cross, Stanwell Road, Feltham, Middlesex TW14 8NX, UK. E-mail: [email protected] In recent years, the survival of young males suffering from cancer has been improved. Development of new techniques such as IVF and intracytoplasmic sperm injection enables even low quality spermatozoa to be used successfully. It is possible therefore to preserve fertility potential of cancer patients before embarking on adjuvant chemotherapy and radiotherapy. Recognizing the importance of protecting the fertility potential of these young males, we present our recommendations for sperm cryopreservation based on the 11 year experience of Bourn Hall and the British Joint Council for Clinical Oncology consultation report. This paper discusses the options available for patients who recover from cancer to become fathers. In many cases patients are concerned about possible abnormalities and teratogenic risks to their future children who have been conceived naturally or by fertility treatment. The data available in the literature may reassure the medical community that there is no such increased risk. However, due to the relatively small number of children born after such treatment, a long-term follow-up is required. There is an ongoing debate regarding the justi®cation for the programme due to the small number of patients who make use of their banked spermatozoa. The authors believe in the importance of protecting the fertility potential of cancer patients, enabling them to father their genetic children in the future while ®ghting their illness. Key words: assisted reproductive techniques/cancer/chemotherapy/semen cryopreservation TABLE OF CONTENTS 1995). Further deterioration has been observed due to the damaging effect of chemotoxic agents on spermatogenesis, which Introduction may be temporary or permanent (Buchanan et al., 1975; Drasga Recommendation for sperm cryopreservation et al., 1983; Fossa et al., 1985; Johnson et al., 1985; Hansen et al., Semen cryopreservation Other considerations before treatment for cancer patients 1990; Presti et al., 1993; Pont and Albrecht., 1997). The sperm Fertility following cancer treatment quality following cancer treatment depends on many factors: the Assisted reproduction treatment after cancer treatment using banked initial sperm characteristics, the type of cancer (Lass et al., spermatozoa 1999a), the chemotherapy and/or radiotherapy agents in use, i.e. Special situations the dose and number of cycles (Meirow and Schenker, 1995; Pont Monitoring of children born after fertility treatment and Albrecht, 1997). It is impossible to predict who will have Should sperm cryopreservation be offered routinely to cancer normal spermatogenesis and who will become azoospermic. patients? Many of these patients are young men who have not started or References completed their families. This factor, combined with the developments in the treatment of male fertility treatment, especially intracytoplasmic injection (ICSI), motivates patients and clinicians to preserve fertility potential of cancer patients Introduction before embarking on adjuvant therapy. Recognizing the importance of fertility potential for young Survival rates of young men suffering from various types of male and female cancer patients, the British Joint Council for cancer have improved dramatically in recent years, due to Clinical Oncology convened a sub-committee comprising medical advanced diagnostic techniques and better treatment modalities. and clinical oncologists and fertility specialists that produced a In many cancer subjects sperm quality is already reduced before consultation report (Working Party of the Joint Council for receiving any treatment (Fossa et al., 1989; Meirow and Schenker, Clinical Oncology, 1998). The following recommendations are 370 Ó European Society of Human Reproduction and Embryology Assisted reproduction for male cancer patients based on this report and our experience at Bourn Hall Clinic, before they have had any chemotherapy or radiotherapy (Lass which has had a successful sperm cryopreservation programme et al., 1998). for cancer patients for the last 11 years. In our clinic we do not actively follow up the patients after completion of their chemotherapy, therefore we do not have data Recommendation for sperm cryopreservation on their survival or whether they have been able to conceive spontaneously. Patients are advised to give semen samples ~6±12 Awareness of the need to refer cancer patients for sperm months post chemotherapy to assess restoration of fertility cryopreservation capacity, but very few have chosen to do so. Men diagnosed with cancer should be referred as soon as possible to a licensed sperm banking unit to give a sample or samples for Semen cryopreservation freezing. We found in a large retrospective study that the median time from diagnosis of cancer to the ®rst semen assessment at Following the detailed consultation, patients obtain sperm Bourn Hall was 3 weeks (range 1 day to 16 weeks). Although the samples by masturbation into two dry pots and the pre-freeze time lag from diagnosis to referral was relatively short in patients semen sample is analysed according to published guidelines with testicular cancer or haematological malignancy, in other (World Health Organization, 1992). Post-thaw analysis is not malignancies there was a delay of a few weeks to referral for done routinely because in many cases the sperm concentration is semen cryopreservation (Lass et al., 1998). The causes of the so low that performing this test would jeopardize the amount delay were: a lower level of awareness of the need for semen available for freezing. Any sample with motile spermatozoa, even banking by the medical team due to a lack of data about the if it is below the required minimum for standard IVF (in our unit a effectiveness of this option, and a longer investigation period to total of 23106 motile spermatozoa/ml), should be frozen. achieve accurate diagnosis and staging of the primary disease in Introduction of intracytoplasmic sperm injection (ICSI) technique solid tumours. Although there was no correlation between the can bypass even the most severe sperm concentration and motility time lag and sperm parameters, it is vital to send these patients for problems (Working Party of the Joint Council for Clinical semen cryopreservation immediately after diagnosis, to enable Oncology, 1998; P®fer and Coutifaris, 1999). Cryopreserv- them to store suf®cient semen samples before starting chemother- ation is performed on any semen sample containing motile apy. spermatozoa by our routine protocol (Richardson, 1979). Semen Our impression, after 11 years experience of sperm cryopre- is diluted with cryoprotectant and 0.7 ml aliquots are transferred servation for these men, is that only a minority of eligible patients to 1.5 ml screw-top plastic vials to enable future use without the is offered sperm cryopreservation. Even men who have previously need to thaw the whole sample. Samples are cooled by suspension been treated with chemotherapy or radiotherapy and who have in vapour phase nitrogen at a rate of approximately ±10°C/min, suffered a relapse of their disease should be referred for for 30 min, and then transferred to liquid nitrogen. Patients are cryopreservation, because two-thirds of them have spermatozoa asked to give a sample every 2±3 days until they have had 12 suitable for freezing. It should be a top priority to increase the ampoules frozen. However, many of them have had to start awareness of general practitioners, oncologists, haematologists chemotherapy treatment immediately and had time to supply only and patients themselves to the new opportunities opened to them one or two samples. Reassuringly, it has been demonstrated that, in recent years (Kliesch et al., 1996; Agarwal et al., 1999; Lass in cancer patients, semen after abstinence of 24±48 h has a post- et al., 1999b). Regrettably, in the UK, sperm cryopreservation is thaw quality similar to semen obtained after longer abstinence not widely available as a National Health Service (NHS)-funded period (Agarwal et al., 1995). Therefore, the period from service (Working Party of the Joint Council for Clinical diagnosis to starting chemotherapy treatment can be shortened Oncology, 1998). without jeorpadizing the frozen sperm quality. The quality of frozen spermatozoa following thawing is The sperm cryopreservation programme for cancer patients at dependent on its initial quality before freezing (Shekarriz et al., Bourn Hall Clinic 1995; Padron et al., 1997; Hallak et al., 1999a). The cryopreser- Patients are referred to our unit by Oncology and/or Haematology vation process itself affects cancer patients' spermatozoa in a Specialists in East Anglia, for semen cryopreservation before manner similar to its effect on donors' spermatozoa (Hallak et al., proceeding with chemotherapy. Their ages range from 14 to 55 1999b). years. They are seen by a specially assigned nurse for the programme, and receive an information lea¯et. This is followed Other considerations before treatment for cancer by consultation with one of the clinic's medical team, when the patients logic of semen cryopreservation and the options for future
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