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Fertility Issues

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    These options may not be appropriate for all patients. Counseling is an important part of the decision-making process for patients. Thinking through these decisions at a time when patients are struggling with issues of life and potential death are often difficult. Patients need to consider costs, stress, time, emotions, and potential inclusion of another individual in the pregnancy process (i.e., a surrogate). For many patients, the financial costs associated with in vitro fertilization and subsequent embryo cryopreservation is cost prohibitive. Consideration also needs to be given to the current rate of failure for in vitro fertilization procedures and the potential adverse effect of malignancy on sperm parameters.[25][Level of evidence: III] A retrospective analysis, with a limited sample size, reported that the oocytes from patients with malignant disorders were of a poorer quality and exhibited a significantly impaired fertilization rate compared with age-matched controls.[25] Importantly, data on the outcome of pregnancies in cancer survivors [28][Level of evidence: III] have not shown any increase in genetically mediated birth defects, birth-weight effects, and sex ratios. Based on the evidence thus far, individuals treated with cytotoxic chemotherapy who remain fertile are not at an increased risk of having children with genetic abnormalities.[3] For all patients who wish to be parents and who have permanent infertility, adoption should be presented as a choice.

    Men who are treated with sterilizing chemotherapy may have semen cryopreserved, yet utilization remains low.[29][Level of evidence: III] In a 15-year study of 776 men with a variety of malignancies, the cumulative rate of using the cryopreserved semen for assisted conception was less than 10% up to 8 years. Younger age at cryopreservation and a diagnosis of testicular cancer were associated with lower utilization.[30][Level of evidence: III] Despite poor postthawing sperm survival rates, intracytoplasmic sperm injection (ICSI) offers the possibility of a pregnancy even if only a single motile sperm is present after thawing.[31][Level of evidence: IV] Cryopreservation of sperm should be recommended even to oncological patients younger than 15 years (provided these patients can produce a semen sample), as overall success rates (defined as the observation of at least a single motile sperm after the thawing procedure) have been found to be similar to those observed in adults.[32][Level of evidence: III] For men who experience retrograde ejaculation after treatment and remain fertile, it is often possible to retrieve live sperm cells. An infertility specialist can retrieve sperm cells from the testicles and from urine. Testis sperm extraction incorporates the removal of testicular parenchyma with processing and isolation of individual sperm cells. This allows for ICSI in azoospermic men. In a retrospective study, 15 of 23 men who were azoospermic after receiving chemotherapy had retrievable testis sperm leading to successful fertilization. Pregnancies occurred in 31% of cycles. Future research is needed to address whether the offspring produced after ICSI techniques are at increased risk of genetic or congenital malformation.[33][Level of evidence: III] Medication can sometimes be used to stimulate the remaining nerves around the prostate and seminal vesicles to convert a retrograde ejaculation to an antegrade ejaculation. In the United States, ephedrine sulfate is most often used; in Europe, imipramine is also used. Pharmacologic agents can also be used to induce an ejaculation (i.e., intrathecal neostigmine or subcutaneous physostigmine). When medication does not work, several other techniques are available and may be recommended, including vibratory stimulation, electroejaculation, direct aspiration of fluid from the vas deferens, perineal needle stimulation, and hypogastric-nerve stimulation. Further review of these treatments and information regarding treatment of infertility and assisted reproductive technology is available.[13,34]

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