Malignancy and Infertility
Malignancy in childhood and adolescence can have a significant effect on future male reproductive capacity. The cancer itself may diminish fertility, and treatment modalities may cause temporary or permanent azoospermia. It is extremely important to discuss fertility preservation with adolescents who are at risk and their parents. Studies have demonstrated that pediatric and adolescent oncology patients are often surprised to learn about cancer-related infertility, and future parenthood is a significant consideration in this population (Schover, Brey, Lichtin, Lipshultz, & Jeha, 2002a, b). Nurses and midlevel providers may be useful in educating oncology patients and their parents so they may move beyond their initial diagnosis and pursue sperm banking if interested.
Testicular germ cell cancer (TGCC) is the most common malignancy in Caucasian males, starting in late teenage years. TGCC may have an adverse effect on semen quality (Petersen, Skakkebaek, Vistisen, Rorth, & Giwercman, 1999) and contribute to the development of hypogonadism through Leydig cell dysfunction (Nord et al., 2003), even in the contralateral testis. Treatment often requires local or total body irradiation at doses that can cause infertility. Similarly, chemotherapy used in the treatment of TGCC may also have an effect on spermatogenesis. Not all testicular tumors in childhood and adolescence are malignant; efforts to preserve testicular tissue are being used more frequently for benign testicular lesions, such as epidermoid tumors, which are often identified preoperatively based on ultrasound appearance (see Figure 3).
Scrotal Ultrasound Demonstrating Epidermoid Tumor of Testis (Excised, Preserving the Remaining Testicular Tissue)
Regardless of the location of the malignancy, pre-pubescent males receiving chemotherapy may be at risk for a cytotoxic insult to the rapidly dividing spermatogonia. This temporary impairment can last up to two years (Levine, Canada, & Stern, 2010). Permanent infertility may result due to the quantitative and qualitative damage to spermatogenic germ cells, particularly with the use of higher-dose alkylating agents.
Before chemotherapy for any malignancy, orchiectomy or radiation therapy in the vicinity of the reproductive organs or total-body irradiation, sperm cryopreservation should be considered and discussed with the adolescent and family because it is the best-established and least-invasive means of preserving fertility in adolescent patients. If masturbation with ejaculation is not a suitable option due to age, discomfort, or illness, other more invasive options exist. Micro-surgical epididymal sperm aspiration, testicular sperm extraction, or electroejaculation under anesthesia can be performed for sperm retrieval for cryopreservation. These procedures may provoke anxiety for the child or adolescent as well as the parents, and thus, education and counseling are critical. Urology nurses can be invaluable in helping these individuals get through such anxietyprovoking and emotional experiences by helping the patient and family interpret complicated data and procedures to help make their best decision.
Hormonal or metabolic causes of infertility in adults include growth hormone deficiency, hyper prolactinemia (such as pituitary adenoma), and thyroid abnormalities. Aside from growth hormone deficiency, these conditions are not typically identified in younger pediatric patients, such as those with Klinefelter syndrome.
Urol Nurs. 2012;32(5):237-248. © 2012 Society of Urologic Nurses and Associates