Sperm Cryopreservation and Recent Advances in Assisted Reproduction Techniques for Cancer Survivors
Sperm Cryopreservation and Recent Advances in Assisted Reproduction Techniques for Cancer Survivors
ABSTRACT & COMMENTARY
Synopsis: A survey of oncologists in Minnesota examined knowledge and attitudes about sperm cryopreservation for male patients with newly diagnosed cancer. Enthusiasm for this undertaking was only moderate, related to lack of information about the technical advances and the improved fertility rates.
Source: Zapzalka DM, et al. Cancer 1999;86: 1812-1817.
With steady improvements in cancer treatment, more patients are being cured of cancer and have an expectation of normal or near normal life span. Many of the most curable malignancies occur in young people. Malignancies such as leukemia, lymphoma, and testicular cancer are not uncommon in young men. Perhaps because there always seems to be great urgency in starting therapy in newly diagnosed patients, issues of long-term family planning are frequently overlooked. For males, the procurement and cryopreservation of sperm can be done. However, the perception is that this is expensive, takes too much time because of the need for multiple donations, that the quality of sperm is often poor even before therapy (related to effects of the cancer), and that the success rate is quite low. I can recall thinking somewhat sardonically, we should be so lucky as to have this patient survive to experience childlessness.
Zapzalka and colleagues surveyed the current knowledge, opinions, and clinical practices of American Society of Clinical Oncology (ASCO) members in the state of Minnesota regarding pretherapy cryopreservation of semen. Forty-six of 165 oncologists (28%) responded to the written questionnaire. The responding oncologists did discuss cryopreservation with their patients, but their enthusiasm for the intervention was only moderate (mean 5.8 ± 2.2 on a scale of 1-10). They perceived the importance of the procedure to the patient to be somewhat greater (6.8 ± 2.5). The factors that were considered important in their recommendation were patient age, type of treatment, type of cancer, and the urgency for starting therapy. Included, but less commonly mentioned, were pre-existing infertility, number of children, marital status, and cost. A majority of respondents knew where patients could go to have sperm cryopreserved, but less than half gave accurate information about the costs of the procedure.
Zapzalka et al speculate that some of the lack of enthusiasm for referring patients for cryopreservation is based upon the assumption that the procedure is likely to be ineffective due to diminished sperm quality, even before chemotherapy, and to the lack of awareness of the recent advances in assisted reproductive techniques. They point out that in vitro fertilization has been greatly enhanced by new intracytoplamic injection techniques. Their survey would indicate that there is a need for re-educating medical oncologists on this topic.
COMMENTARY
Infertility is common in cured cancer patients. Whether this is the result of therapy or just associated with the underlying disease is not completely clear, and it is likely that both factors make a contribution. But the fact remains that fertility rates are low in this population.1,2 Assisted reproductive technology has, in recent years, progressed to such an extent that in vitro fertilization using small quantities of male sperm has been successful in the majority of cases.3 The technique of injecting single sperm directly into the egg cytoplasm has been a major breakthrough in this technology and men who once had little or no chance of producing a pregnancy through assisted techniques now have fertility rates approaching that of couples undergoing standard in vitro fertilization in whom male infertility is not involved.
The data from this survey would indicate that oncologists are not aware of these advances. Of course, this was a small survey with about 25% of respondents from a single state. Yet, the responders, if anything, were probably more likely to be aware or sensitive to the issues presented and, still, it appears that there is both misinformation and lack of awareness of recent advances. Possibly this is a regional phenomenon due to local cultural or practice patterns, a caveat not mentioned by Zapzalka et al, but this seems unlikely. More likely is that currently practicing medical oncologists have yet to witness or learn about these advances and, thus, maintain an attitude toward sperm cryopreservation based upon prior disappointments. If, indeed, these advances are as successful as reported, oncologists may be doing a disservice to those selected patients in whom post-therapy family planning will become an issue by foregoing a discussion and facilitation of semen collection and cryopreservation before therapy.
References
1. Whitehead E, et al. Cancer 1982;49:418-422.
2. Chatterjee R, Goldstone AH. Bone Marrow Transplant 1996;17:5-11.
3. Palermo GD, et al. Fertil Steril 1996;65:899-908.
Which of the following statements about referring patients for sperm cryopreservation is true?
a. It should be reserved for patients who have normal, pretherapy sperm counts as in vitro techniques for fertilization are unsuccessful with less than optimal sperm.
b. In vitro fertilization is unlikely to be successful in just about all cases and, thus, cryopreservation of sperm is not likely to be of value.
c. New technical advances have made in vitro fertilization much more successful and patients should be made aware that sperm cryopreservation is an option to allow later pregnancies.
d. Several semen collections will be necessary because the new techniques for in vitro fertilization require large numbers of sperm.
e. It should not be offered because most men with cancer have defective sperm.
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