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CASE HISTORY

Case History

image A 24-year-old man presented with a 4-week history of a unilateral testicular lump. Ultrasound scan showed a 4 cm hypoechoic, hypervascular mass in the left testis suspicious for malignancy. All his tumour markers (alpha-fetoprotein, beta-hCG, LDH) were normal. His staging CT showed no evidence of disease elsewhere in the chest or retroperitoneum. He was listed for an urgent orchidectomy, which confirmed a fully excised stage pT1 seminoma with rete testis involvement. Following orchidectomy, he was advised to have adjuvant chemotherapy with carboplatin.

He was referred to the fertility clinic for semen analysis and cryopreservation prior to starting chemotherapy. The semen analysis showed complete azoospermia (no sperm in the ejaculate). The patient was offered surgical sperm retrieval pre-chemotherapy, however following the orchidectomy, he developed a large deep vein thrombosis (DVT) and was commenced on anti-coagulation therapy. In view of the increased risk of bleeding, the surgical sperm retrieval was cancelled and he was advised to commence chemotherapy without any further delay.

Two years after completion of treatment he was seen again in the fertility clinic with his partner, as he wanted to start a family and discuss fertility options. His hormone profile showed a raised FSH (20 IU/l) and LH (9 IU/l) and a normal testosterone level. Semen analysis showed a normal volume azoospermia in keeping with nonobstructive azoospermia. He was referred for surgical sperm retrieval and sperm were successfully retrieved and frozen using a microsurgical technique (microTESE [testicle sperm extraction]). The couple went onto have in-vitro fertilization (IVF) treatment with intracytoplasmic sperm injection (ICSI) using the cryopreserved sperm, which resulted in a live birth of a healthy child after the first cycle.

How common is sub-fertility in testicular cancer and why is it important?

How do testicular cancer and its treatment affect fertility?

When is the best time to cryopreserve semen in testis cancer?

What are the options for the azoospermic man with testicular cancer?

How common is sub-fertility in testicular cancer and why is it important?

Testicular cancer (TC) is the most common malignancy to affect men in their fertile years (15–35 years). Approximately 50% of men with TC will be sub-fertile at presentation, and approximately 1 in 10 will have azoospermia,1 although azoospermia rates of 6–24% have been reported.2 Given the increasing incidence (UK statistics 2,400 new cases/year) and improved survival (98% at 10 years), a greater number of men are surviving their cancer diagnosis and treatment and looking to return to a normal life and fertility. The development of infertility in addition to a diagnosis of cancer is associated with a significantly greater level of stress and depression for the patient and their partner.3

How do testicular cancer and its treatment affect fertility?

Men with testicular cancer can develop impaired fertility due to the tumour:

  1. There is an aetiological link between TC and ...

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