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18th Meeting of the EAU Section of Oncological Urology (ESOU21)

ESOU 2021: Fertility Preservation in Testicular Cancer Patients

(UroToday.com) To conclude the rare tumors session at the European Association of Urology (EAU) Section of Oncological Urology (ESOU) 2021 Virtual meeting, Dr. Julien Van Damme discussed fertility preservation in testis cancer patients. By way of background, Dr. Van Damme notes that testicular cancer is the most common cancer in men of reproductive potential, with a peak incidence between 15-35 years of age and an associated high survival rate. It is estimated that 50% of patients have impaired fertility at presentation, and 25% have azoospermia prior to treatment, with <1/3 of patients undergoing sperm banking prior to therapy. Gonadotoxic therapies cause an overall decrease in male fertility by 30% and there is currently no method to predict which patients will become azoospermic after treatment.1 As follows is a summary of the relationship between testicular cancer and infertility prior to treatment:




ESOU_infertility.png



It is estimated that radical orchiectomy results in sperm impairment, but with the recovery of fertility after 2-3 years and a successful conception rate of 80%. For those undergoing retroperitoneal lymph node dissection (RPLND), the summarized data suggests that retrograde or anejaculation occurs in 0-14% of patients, with a successful subsequent conception rate of 59-78%. Among patients undergoing radiotherapy, 24% are azoospermic at 6 months, but with recovery at 24 months and a successful conception rate of 66%. As follows is a table displaying the relationship between radiation dose and the effect on fertility:

ESOU_anejaculation.png



For patients undergoing chemotherapy, recovery of spermatogenesis occurs in 12 months if less than 2 doses of BEP are received, compared to 24 months for those receiving 2 or more doses; no recovery of spermatogenesis has been reported for patients receiving >5 cycles of BEP. Dr. Van Damme notes that it is important for patients receiving chemotherapy to avoid conception for 6-18 months.

The EAU guidelines have a strong recommendation for discussing sperm banking with all men prior to starting treatment for testicular cancer, typically via cryopreservation of sperm. One interesting modality for sperm banking is onco-micro TESE. Moody and colleagues assessed the frequency of spermatogenesis in 103 patients with testicular cancer, finding that spermatogenesis was present in 70% (72/103) of patients, was widespread in 63% (45/72), and focal in 38% (27/72). Thus, these data would suggest that there may be support for a microsurgical approach to sperm retrieval at the time of orchiectomy to maximize success:

ESOU_orchiectomy.png



Dr. Van Damme states that management of post-treatment infertility in the post-chemotherapy setting should be TESE, while in the post-RPLND setting there is the opportunity to use alpha-adrenergics and/or electrostimulation. To conclude his presentation, Dr. Van Damme provided the following figure to summarize the testis cancer care pathway for the best oncological outcomes and maximal fertility preservation:

ESOU_TESE.png



Presented by: Julien Van Damme, MD, PhD Student, CHU UCL-Godinne, CUSL-BXL, Pietrebais, Belgium

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia Twitter: @zklaassen_md during the 18th Meeting of the EAU Section of Oncological Urology (ESOU21), January 29-31, 2021

References:
  1. Moody JA, Ahmed K, Yap T, et al. Fertility management in testicular cancer: the need to establish a standardized and evidence-based patient-centric pathway. BJU Int 2019 Jan;123(1):160-172.
  2. Moody JA, Ahmed K, Horsefield C, et al. Fertility preservation in testicular cancer – predictors of spermatogenesis. BJU Int. 2018 Aug;122(2):236-242.