Testicular cancer (TC) and its necessary treatments can significantly affect a man’s ability to have biological children, a condition known as clinical infertility. Infertility is the inability to achieve a pregnancy after one year of regular, unprotected intercourse. Because TC most commonly affects men between the ages of 15 and 35, fertility preservation is an important consideration for many patients. The impact on fertility can stem from the disease itself, the subsequent surgical removal of the testicle, or the toxic effects of follow-up therapies.
How the Disease Itself Affects Sperm Production
The presence of a testicular tumor can negatively influence sperm production even before any treatment begins. Over half of men diagnosed with testicular cancer already have a reduced sperm count, a condition called oligospermia, or even no sperm at all, known as azoospermia. This reduction is partly due to the direct damage the tumor causes by replacing healthy tissue in the affected testicle.
The cancer can also cause systemic changes that disrupt the hormonal balance necessary for making sperm. The hypothalamic-pituitary-gonadal (HPG) axis controls testicular function, and certain tumor markers, like beta-human chorionic gonadotropin (beta-HCG), can interfere with this regulatory feedback loop. This disruption can lead to abnormal levels of hormones like luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which stimulate sperm creation. Systemic inflammation associated with a cancer diagnosis can also impair the process of spermatogenesis throughout the body.
Risks Associated with Testicular Cancer Treatment
The primary treatment for testicular cancer, a radical inguinal orchiectomy, involves the surgical removal of the cancerous testicle. While removing one testicle reduces the overall sperm-producing capacity, the remaining testicle can often compensate and maintain fertility. However, if the remaining testicle already had reduced function due to the cancer, or if both testicles are affected, this procedure can lead to infertility.
Chemotherapy, particularly regimens that include platinum-based drugs like cisplatin, is a major risk factor for long-term infertility. These drugs are designed to target and destroy rapidly dividing cells, including the precursor cells that develop into sperm. Chemotherapy often causes a temporary period of no sperm production (azoospermia), but the risk of permanent damage is dose-dependent. While sperm production may return within one to two years for most men, some will experience irreversible damage, especially with higher cumulative doses of cisplatin.
Radiation therapy directed at the lymph nodes in the abdomen or pelvis also carries a risk to fertility. Although the remaining testicle is typically shielded with lead blocks during radiation, scatter radiation can still reach the sperm-producing tissue. Even low doses of radiation can impact sperm concentration, and doses over 4 Gy can cause permanent germ cell damage. Recovery of sperm function after radiation can take anywhere from 18 months to over five years, depending on the total dose received.
Retroperitoneal lymph node dissection (RPLND), used to remove abdominal lymph nodes, can affect fertility through a different mechanism. This surgery risks damaging the nerves that control ejaculation. Injury to these nerves can result in retrograde ejaculation, where semen flows backward into the bladder instead of out of the penis, preventing natural conception. Modern nerve-sparing techniques have significantly reduced this risk, with success rates of preserving normal ejaculation often exceeding 95% in experienced centers.
Evaluating Fertility Status
Assessing fertility status involves a clinical evaluation, which should ideally occur before any cancer treatment begins. The primary diagnostic tool is a semen analysis, which provides a detailed snapshot of reproductive health. This test measures several metrics, including sperm concentration (count), motility, and morphology.
Pre-treatment semen analysis establishes a baseline and helps determine the need for fertility preservation. Studies show that men with testicular cancer often have lower sperm quality compared to men with other cancers, with a high percentage exhibiting abnormal morphology and reduced concentration even before therapy. After treatment is complete, repeat semen analyses are performed periodically to monitor the return of spermatogenesis, indicating whether the damage was temporary or permanent.
Options for Preserving Future Fertility
Fertility preservation safeguards a patient’s ability to have biological children later. The primary option is sperm banking, or cryopreservation, which involves collecting and freezing sperm samples before treatment starts. The cryopreservation process allows sperm to remain viable for many years, offering a secure option for future family planning.
Patients are generally advised to collect multiple samples over several days to maximize the number of sperm stored. Even if a man’s initial semen analysis shows a low count, banking any available sperm is recommended, as assisted reproductive technologies like Intracytoplasmic Sperm Injection (ICSI) can utilize even a few viable sperm. For men who experience permanent azoospermia after treatment, Microdissection Testicular Sperm Extraction (microTESE) is an option, where a surgeon attempts to retrieve sperm directly from the testicular tissue. This technique offers a path to paternity even when pre-treatment banking was not possible.