We tend to take many things for granted on this good earth. The ability to have offspring is often one of them. That is, until a serious medical illness like cancer rears it ugly head and puts fatherhood at risk. Not only does cancer treatment often have sterilizing effects on fertility, but the mad rush to treat the disease can sideline efforts to preserve future fertility. Fire the canons of cure and check for collateral damage later.
Thankfully, medical care is now better at not only curing cancer, but also improving the quality of life among survivors. And without a doubt, fertility is a key quality of life issue after cancers are cured. For men, the battle for fertility is fought on two fronts: fertility preservation seeks to protect men (and boys) from the sperm-damaging effects that often accompany cancer treatment; fertility restoration empowers male survivors to overcome infertility so that they may father children.
Classic techniques for fertility preservation in men include gonadal shielding and sperm banking. Gonadal shielding uses lead-based devices to protect the testicles from the sterilizing effects of radiation treatment. Sperm banking is the process of freezing healthy sperm before cancer treatment starts for later use to conceive. But there is more. For patients who are too young to bank sperm, for those who have precious little time to bank sperm, or for those who have no ejaculated sperm, testis sperm retrieval by biopsy (TESE) or needle aspiration (TESA) for banking is now possible before cancer treatment. And, in selected cases of testicular cancer, we no longer need to remove the whole testis, but can now remove only the cancerous nodule within the testicle, leaving the rest intact and fertile. Even in cases in which the entire testicle must be removed, we can freeze sperm from the testicle immediately after it is taken out and before it is sent for medical examination for cancer. These are now considered routine approaches to fertility preservation in men.
Fertility restoration for men has also seen real advances. Sperm “mapping” can help men who no longer have sperm in their ejaculate due to cancer treatment. It’s a non-invasive and non-surgical way to determine whether sperm is present in the testicle, despite there being no sperm in the ejaculate. In men who have nerve injuries from cancer surgery that affect their ability to ejaculate, a special medical instrument can produce an ejaculate for fertility purposes in a process termed “electroejaculation.” These techniques have become valuable tools to help men who were told they were “sterile” after cancer treatment in the past to become fathers today.
The most exciting area of research around fertility restoration involves stem cell technology. The “promise” of stem cells in curing disease will likely find its way into the fertility field as well. In boys with cancer, ejaculated sperm is not present. Despite this, it may be possible to freeze the stem cells in their testicles before sterilizing cancer treatment. After thawing, these same cells may be used to create sperm after maturation in a Petri dish or after putting them back into the testicle. It’s been done in animals but not yet in humans, but we’re really, really close. Also on the horizon is the ability to take skin from a sterile man, convert skin cells into stem cells, and then “drive” them to become sperm in a dish. So, soon, fertility preservation may be going from science fiction to reality.
