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CASE HISTORY

Case History

image A 37-year-old male diagnosed with stage 4 poorly differentiated colon cancer was referred with his 32-year-old female partner. He had undergone 5 months of chemotherapy and immunotherapy to enable definitive surgery with total pelvic exenteration (TPE) followed by maintenance immunotherapy. His treatment included oxaliplatin, fluorouracil, capecitabine, irinotecan, bevacizumab, and pembrolizumab. He had not stored sperm prior to chemotherapy as he was too unwell at the time. Semen cryopreservation was attempted following chemotherapy, before surgery, but he was found to be azoospermic. Despite the advanced stage of cancer at diagnosis and extensive pelvic surgery, he remained fit and active with a good quality of life. Three years later there was no visible disease on imaging. He remained on continuous immunotherapy with pembrolizumab. Having survived his advanced cancer, his thoughts now turned to starting a family.

His 34-year-old partner had normal periods which were becoming shorter and recently lasting 1 day only. She was fit and healthy apart from a microprolactinoma managed successfully with cabergoline. Routine investigations showed reduced ovarian reserve (anti-müllerian hormone—AMH) 4.6 pmol/l (6.5–19.8 pmol/l). The couple were reviewed in a combined andrology clinic by reproductive specialists and andrology consultants. Treatment with both donor sperm as well as their own gametes was discussed.

The couple were offered a synchronized microdissection testicular exploration and sperm extraction (micro-TESE) with egg retrieval. This allowed the gametes to be retrieved on the same day to avoid freezing before intracytoplasmic sperm injection (ICSI). The immunotherapy was stopped 6 months prior to the planned procedure. On the day of the synchronized micro-TESE, occasionally motile sperm were retrieved; in addition, three ampoules of sperm were frozen. Four eggs were retrieved, with two progressing to embryo transfer. Unfortunately, no pregnancy was achieved.

Three months later, a second cycle was undertaken using frozen micro-TESE sperm. Ten eggs were retrieved this time, five fertilized, and two transferred. This resulted in a viable intra-uterine singleton pregnancy. Nine months later, a healthy baby girl was born who is thriving and growing well.

What fertility treatments are available for males with azoospermia following chemotherapy and how successful are these?

Synchronized micro-TESE with egg retrieval: Does it matter if fresh or frozen sperm is used?

What do we know about the effect of chemotherapy and immunotherapy on testicular function?

What fertility treatments are available for males with azoospermia following chemotherapy and how successful are these?

The treatment options for azoospermia following chemotherapy include assisted conception with either donor sperm or surgically retrieved sperm from the patient. Fertility treatment using donor sperm is increasing, but still represents under 20% of total treatment cycles in 2016.1 Couples tend to avoid donor sperm as they prefer biologically related children. Furthermore donor-conceived children have the right to access donor information when they reach 18 years of age. Donor sperm, however, is associated with higher fertilization and clinical pregnancy rate compared to surgically retrieved sperm in men with ...

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