Akanksha Mehta, M.D., M.S.
Department of Urology, Emory University School of Medicine, Atlanta, GA
Fertility preservation (FP) in men refers to the process of saving or protecting sperm or testicular tissues, so that they may be used to father biological children in the future. Although a cancer diagnosis is the most common reason to consider FP, the indications for FP are, in fact, much broader: genetic disorders like Klinefelter syndrome, which results in an irreversible decline in testicular function; endocrine (hormone) disorders that require testosterone replacement therapy; abdominal or pelvic surgery with the potential to affect ejaculation; spinal cord injuries; and trauma involving the genitourinary tract; as well as non-medical indications such as military deployment. In recent years, interest in elective FP has also increased among transgender patients planning to embark on hormone therapy, and patients concerned about potential upcoming exposure to infectious organisms, such as the Zika virus, which are known to have a detrimental effect on reproductive outcomes.
There are several options available for FP, each with its own advantages and disadvantages. The “best” FP option may vary from patient to patient, and depends on the underlying reason for fertility preservation, as well as the patient’s goal for future fertility. The most commonly available options are summarized below:
It seems that it would be helpful to refer to a few other documents that will be on the site. For example, the PVS and EEJ was covered a little more in the ejaculatory dysfunction document.
- Gonadal shielding: Radiation therapy, used for the treatment of many cancers, can have severe and long-lasting toxic effects on testicular function and sperm production. Radiation patients can often use a radiation shield to protect testicular tissues from the damaging effects of radiation.
- Semen cryopreservation: The simplest option for fertility preservation involves cryopreservation, or freezing, of an ejaculated semen specimen. Depending on the count and quality of sperm in the specimen, ejaculated sperm can be used to achieve a pregnancy with intrauterine insemination (IUI), or assisted reproductive technology such as in vitro fertilization (IVF).
- Penile vibratory stimulation (PVS): For patients who are unable to provide an ejaculated semen sample, a non-invasive vibratory device applied to the head of the penis can help trigger the ejaculation reflex in order to produce semen for cryopreservation. PVS can be performed in the office, and has been successfully used in men with spinal cord injury and peripheral neuropathy (nerve dysfunction).
- Electro-ejaculation (EEJ): EEJ is an alternative to PVS, and involves the use of a rectal probe to apply electrical stimulation to pelvic nerves, in order to trigger ejaculation. EEJ is more invasive than PVS, and is usually performed under anesthesia. Similar to PVS, indications for EEJ include spinal cord injury, peripheral neuropathy, and, on occasion, religious objections to masturbation.
- Epididymal sperm aspiration: Patients who do not have sperm in the ejaculate due to a blockage in the reproductive tract can have sperm extracted in the office by inserting a needle through the scrotal skin into the epididymis. Sperm aspirated from the epididymis can also be cryopreserved, and has to be used in conjunction with IVF in order to achieve a pregnancy.
- Testicular sperm extraction: Patients who do not have sperm in the ejaculate due to a defect in sperm production can undergo detailed testicular surgery to find and selectively biopsy rare areas of sperm production. Sperm surgically retrieved in this way can be cryopreserved, and has to be used in conjunction with IVF for reproduction.
In addition to the options listed above, several experimental therapies for fertility preservation are also under investigation. These include the use of patient-specific stem cells (unspecialized cells in the body) to produce mature sperm. Advances in male reproductive medicine are expected to make such options a reality for patients in the next one or two decades.
There are strict federal guidelines surrounding the cryopreservation of sperm and testicular tissues, and their eventual use for reproduction. The U.S. Food and Drug Administration mandates that all patients cryopreserving ejaculated or surgically-retrieved sperm undergo infectious disease screening, and complete a special written consent form documenting how they wish their cryopreserved samples to be handled in the event of their death or incapacitation.
Post-pubertal adolescents are also candidates for FP, and should be active participants in deciding whether to undergo FP. Since adolescents under 18 years of age are technically minors, consent for FP, if desired, must be provided by their parent or legal guardian.
Successful pregnancies and healthy live births have been reported using both ejaculated and surgically-retrieved sperm. FP is recognized to be safe and effective, and should be considered by all men who are worried about future fertility for medical or personal reasons.
References:
1. Urology Care Foundation Fertility Preservation Fact Sheet: https://www.urologyhealth.org/educational-materials/fertility-preservation-fact-sheet
2. American Society for Reproductive Medicine Fertility Preservation Patient Resources: http://www.asrm.org/topics/topics-index/fertility-preservation/
3. Livestrong Foundation Male Fertility Preservation: https://www.livestrong.org/we-can-help/just-diagnosed/male-fertility-preservation