While this is likely reassuring to patients, it overlooks one of the most impactful complications associated with cancer: cancer-related male infertility. Men of the affected age group can find themselves in situations where the treatment (i.e. orchiectomies, chemotherapies) or the cancer itself, render often young men with limited future reproductive and family planning options. Under the most unfavorable circumstances, testicular cancer can lead to low sperm counts and even planned sperm banking is a poor option. Recently, significant advancements in reproductive technology have drastically improved surgical sperm retrieval and sperm cryopreservation rates.
Our recently published surgical video article in Fertility and Sterility (Ex-Vivo Microscopic Onco-Testicular Sperm Extraction: Step by-Step Surgical Technique at Time of Radical Orchiectomy) details a 37 y/o male with a history of right testicular seminoma, status post right radical orchiectomy, who presents with a left testicular mass concerning for malignancy. Prior pre-operative ultrasound revealed a diffuse hypoechoic mass measuring 6cm, and CT scans revealed a large retroperitoneal conglomeration of lymph nodes consistent with clinical stage 2C testicular seminoma. Prior sperm banking retrieval attempts, including Microscopic Oncologic Testicular Sperm Extraction (Micro-OncoTESE) at the time of the first orchiectomy and sperm/semen analyses prior to/post the first orchiectomy, failed to identify any sperm. Despite this, the patient remained interested in fertility preservation (i.e. sperm cryopreservation) at the time of this second orchiectomy.
Ex-Vivo Micro-Onco TESE remains the best currently available option for this patient, as the gold-standard treatment plan for nonobstructive azoospermia (due to comparably high success rates in sperm retrieval/cryopreservation). Additional MicroTESE advantages include being able to extract a larger number of total sperm, and a lower risk of complications such as infection, hemorrhage, and surrounding organ damage. Notably, it has been found that the sperm retrieval rate of MicroTESE is strongly influenced by the surgeon’s case volume and expertise. Hence it is imperative to consider a urologist’s expertise to maximize the potential for a successful sperm retrieval procedure.
In our case presentation reported in this surgical video, pre-operative HCG was measured at 17.3iU/mL, AFP was measured at 4.2 ng/dL, and LDH was measured at 304 U/L. The left radical orchiectomy confirmed a 7.2cm pure seminoma with rete testis and lymphovascular invasion. The procedure proceeded without complications, with 10 grams of sperm-associated tissue extracted (i.e Sertoli cells, spermatogonia, spermatocytes, and potentially early and late round spermatids) and placed into a solution of sperm media. This tissue was sent off to the in vitro fertilization lab, for further sperm identification and sperm perseveration. Post-operative HCG fell to 7.9 iU/mL and AFP fell to <2 ng/dL. Viable sperm (specifically 5-7 per vial) were successfully identified and collected via the ex-vivo micro-OncoTESE procedure. As a result, the andrology lab was able to cryopreserve a total of 200,000 motile sperm for future assisted reproductive technology with IVF or IVF-ICSI.
Written by: Christopher Villota,1 Omer Raheem, MD2
- University of Chicago Pritzker School of Medicine
- University of Chicago Medical Center