To Preserve Fertility After Cancer
words by maryann brinley / photograph by pete byrony
he healthy-looking young man, in his late twenties, walked into Hossein Sadeghi-Nejad’s office for an evaluation of possible male infertility. His wife had sent him after the obstetrician/gynecologist doing her fertility workup noticed that he had an abnormal semen analysis. They were trying to become pregnant.
A professor of urological surgery and expert in male reproductive medicine at UMDNJ-New Jersey Medical School (NJMS), Sadeghi-Nejad was pleased to see this male partner being evaluated because men in fertility crises are not always given the benefit of a full medical evaluation. The high-intensity focus is mainly on the woman. “In many cases, failing natural conception after a few trials, the couple will be directed to high level assisted reproduction without an adequate work-up for the male.” This man was lucky. Another unfortunate and frustrating issue which disturbs Sadeghi-Nejad is that future fertility is not discussed routinely with men before they undergo cancer therapy. “I see many men who are cancer survivors and wish to consider fatherhood but alas, it may be too late.
“This patient’s story illustrates a number of very important points,” he says. It happened last year. After taking a detailed medical history, the doctor asked him to step into the examining room for a physical. “He had not complained of testes pain or any other symptoms,” Sadeghi-Nejad explains. “But it was immediately apparent that something was drastically wrong with one testis because it was hard as a rock and three times larger than the other.” This is a clinical picture where in most cases, according to the expert, it’s “cancer until proven otherwise.”
Blood work was ordered immediately to determine the type of malignancy and an ultrasound was also scheduled.The race was on. A CT scan was done right away to make sure there was no evidence of metastasis and within days, this man was scheduled for a radical orchiectomy, or removal of the affected testis and spermatic cord. It was cancer. Because of Sadeghi-Nejad’s intervention, the couple was also counseled about the possibility of sperm banking before any therapy was initiated — in spite of that rush to remove his cancer. They also took the time to go to a center where sperm banking could be performed. This turned out to be a critical step.
“Indeed, many patients who undergo therapies for testis cancer, Hodgkin’s disease and even prostate cancer are not thinking of fertility when they are first diagnosed. I cannot emphasize enough the value of pre-intervention counseling.”
The full impact of the counseling became even more significant when his cancer turned out to be of an unusual type, requiring additional surgery. After consultations with top oncologists, lymph nodes were removed. “He came through all this brilliantly and is doing well,” his doctor says. “The important point here is that his pathologies and treatments will result in abnormal or sometimes the absence of sperm in the ejaculate.” Yet, because of that sperm banking, “he and his wife can still pursue their wish for parenthood.”
In cancer of a testis, the bad news is also that “the other, or good, side may be affected. There is a near certain decrease in number of sperm by about 50 percent.” For his patient with testicular cancer last year, that additional surgery also raised the possibility that he might not be able to ejaculate due to the effects on the sympathetic nerves.
Sadeghi-Nejad, Chief of Urology for the VA New Jersey Health Care System and also Director of the Center for Male Reproductive Medicine at Hackensack University Medical Center, believes that sperm cryopreservation is the “most prudent approach” to protect fertility in male cancer patients. “It can be difficult to predict the final effect on the fertility potential of any patient,” Sadeghi-Nejad explains. Even if the anti-cancer treatment doesn’t lead to infertility, he raises the fear of single gene and chromosomal mutations that might be induced in the surviving germ cells and passed on to children, eventually leading to genetic diseases. Any type of cancer can also have adverse effects because of nutritional deficits caused by symptoms, the hyper-metabolic state of the cancer itself and altered blood flow. Chemotherapy and radiation can cause long- term or even permanent infertility in men.
While studies indicate sperm counts may eventually return, Sadeghi-Nejad is cautious. “I generally recommend that patients wait at least 18 months after chemotherapy before attempting conception or moving on with assisted reproduction. We have to exercise extra vigilance.” These are the cases where sperm banking wasn’t done prior to the cancer intervention. “Sperm retrieval can still be successful for many of these patients,” he says. Testicular tissue cryopreservation can also be done when there are no sperm in a man’s ejaculate. “I perform this operation microsurgically so the most promising seminiferous tubules (where sperm are produced) that may contain sperm can be identified and removed for sperm retrieval.”
The good news in all this is that “the technologies now available for sperm and testis tissue freezing are very advanced and readily available. At each step, however, the goal is to use the least invasive yet most effective possible therapy.” Sadeghi-Nejad explains that even immature testis tissue in boys who have not yet gone through puberty but who are facing cancer therapies can be saved. He is one of just a few male fertility experts in New Jersey who can offer specialized care, microsurgery and testicular biopsy to retrieve sperm even in cases of azoospermia, where no measurable amounts of sperm are in semen.
Sadeghi-Nejad is writing a chapter for Fertility Preservation in Men with Cancer (Cambridge University Press) and works closely with Peter McGovern, MD, NJMS professor and Director of the Division of Reproductive Endocrinology and Infertility, as well as Aimee Seungdamrong, MD, Director of Fertility Preservation and a principal investigator for the National Physicians Cooperative of the Oncofertility Consortium. “Any physician caring for cancer patients in their reproductive years must take the time to provide the latest information pertaining to the disease as well as future expectations,” insists Sadeghi-Nejad, “especially the chances of fatherhood and the simple steps that can be taken to optimize outcomes.”
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