Testicular cancer (TC) is the most common cancer diagnosed in men between the ages of 15 and 35. Because this disease affects men who are often planning or building families, the diagnosis immediately raises significant questions about future fertility. TC and its subsequent treatments often affect a man’s ability to father children. Addressing fertility concerns is a mandatory part of the initial diagnosis and treatment planning to ensure the best outcomes for both survival and quality of life.
How Testicular Cancer Itself Affects Sperm Production
The presence of testicular cancer can impair sperm production even before any medical treatment has begun. Studies show that between 30% and 50% of men diagnosed with TC already have low sperm counts or poor sperm quality at the time of diagnosis. This initial subfertility is caused by a multi-faceted biological impact of the disease on the body.
The tumor’s growth physically replaces healthy tissue, directly reducing the volume of the testicle capable of producing sperm. The cancer can also disrupt the endocrine system; some tumors produce hormones like human chorionic gonadotropin (HCG) which upset the hormonal balance necessary for healthy sperm creation. Systemic stress and inflammation associated with cancer also contribute to lower sperm quality and concentration.
The standard initial treatment for TC is a radical inguinal orchiectomy, the surgical removal of the affected testicle and spermatic cord. Although the remaining testicle usually compensates by increasing hormone and sperm production, fertility is often compromised from the outset. This is due to the combination of pre-existing sperm abnormalities and the surgery itself.
Treatment Effects on Reproductive Health
The most significant impacts on reproductive health generally stem from the necessary cancer treatments that follow surgery. Chemotherapy, radiation, and additional surgery each carry specific risks for fertility.
Chemotherapy is highly effective against testicular cancer cells, but cytotoxic agents are toxic to germ cells, the rapidly dividing cells responsible for sperm production. This treatment typically causes temporary azoospermia (no sperm) or severe oligospermia (very low sperm count) in most patients. While sperm production often recovers, the risk of permanent infertility increases with the intensity and cumulative dose of the chemotherapy administered.
Radiation therapy, if used to treat lymph nodes in the abdomen or pelvis, can damage the testicle through scatter radiation. Even when the testicle is shielded during the procedure, a small dose of radiation can still reach it and impair spermatogenesis. The damage is dose-dependent; recovery can take 18 months for a low dose, but may be significantly delayed or permanent if the dose is higher.
Retroperitoneal Lymph Node Dissection (RPLND) is sometimes necessary to remove lymph nodes in the abdomen. The primary risk to fertility is damage to the sympathetic nerves that control ejaculation, leading to functional infertility known as retrograde ejaculation. In this condition, semen flows backward into the bladder instead of exiting the body. Fortunately, modern nerve-sparing approaches have dramatically reduced this risk, preserving antegrade ejaculation in over 97% of patients.
Fertility Preservation Options
Given the significant risk of infertility from systemic treatments, fertility preservation must be discussed immediately upon diagnosis, ideally before any treatment begins. Sperm cryopreservation, commonly known as sperm banking, is the most accessible option. This involves collecting, analyzing, freezing, and storing semen samples for future use in assisted reproductive technologies (ART).
The best time to bank sperm is before the radical inguinal orchiectomy, as sperm concentration and motility may decrease following the surgery. Critically, cryopreservation must be completed before the patient receives the first dose of chemotherapy or radiation, due to the immediate gonadotoxic effects of these treatments. A consultation with a reproductive specialist should be one of the first steps after a TC diagnosis to facilitate this process promptly.
Even if the initial sperm sample has a low count or poor quality, it may still be sufficient for future use with advanced techniques like Intracytoplasmic Sperm Injection (ICSI). While sperm banking is strongly recommended, some men do not pursue it due to financial cost, the emotional shock of the diagnosis, or the rapid timeline for starting treatment. For men who cannot ejaculate a sample, options like Testicular Sperm Extraction (TESE) exist.
Long-Term Recovery and Monitoring
The long-term outlook for fertility after testicular cancer treatment is generally positive, although recovery requires patience and monitoring. For men who received only chemotherapy, the sperm-producing cells often regenerate, and fertility typically returns within one to five years post-treatment. The average time for sperm count to normalize is within two years after the final dose of chemotherapy.
Monitoring involves regular semen analysis, usually starting six to twelve months after the completion of therapy. This testing helps determine the status of sperm production and guides future family planning decisions. Monitoring of hormonal levels is also necessary, as the remaining testicle may not always produce sufficient testosterone, which is easily managed with replacement therapy.
Many men successfully conceive naturally following testicular cancer treatment, and there is no evidence that conception after treatment leads to birth defects or childhood malignancies. For those who struggle to conceive naturally, assisted reproductive technologies using either recovered sperm or previously banked sperm offer high success rates.