1 Fertility and Reproductive Medicine Laboratories, Department of Obstetrics and Gynaecology, Royal Free and University College Medical School, University College Hospitals Trust, Rosenheim Building, 25 Grafton Way, London WC1E 6DB, 2 Department of Obstetrics and Gynaecology, Royal Free and University College Medical School, 8896 Chenies Mews, London WC1E 6DB and 3 Middlesex Hospital, The Institute of Urology and Nephrology (St Peters Hospital), London W1N 8AA, UK
4 To whom correspondence should be addressed. Email: g.bahadur{at}ucl.ac.uk
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Abstract |
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Key words: azoospermia/cancer/gonadotoxicity/oligozoospermia/quality
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Introduction |
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Improved patient survival rates coupled with advances in reproductive technologies such as IVF and ICSI mean that adult cancer patients can now be offered sperm cryopreservation (Hallak et al., 1999; Bahadur, 2000
). However, factors such as the post-treatment semen status, recovery of sperm and safety issues have attracted enormous clinical and medico-legal attention (Byrne et al., 1987
; Meistrich, 1993
; Robbins et al., 1997
; Martin et al., 1999
; Chatterjee et al., 2000
; Arnon et al., 2001
; De Mas et al., 2001
; Bahadur et al., 2002
; Frias et al., 2003
; Codrington et al., 2004
; Deane et al., 2004
; Seli et al., 2004
).
This study assesses the semen quality of patients before and after gonadotoxic treatment. The data were also analysed in order to identify predictors or associations of sperm loss and recovery.
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Patients and methods |
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The patient characteristics such as age and disease were recorded. The patients were placed into one of five groups according to their underlying disease: leukaemia, lymphoma, testicular cancer, benign conditions which required chemotherapy (Crohns disease, renal lupus and musculoaponeurotic fibromatosus) and other malignant neoplasms (soft tissue sarcomas, osteosarcoma, prostate and skin cancers).
Two pre-treatment semen samples were collected from each patient. All patient follow-up remained the same in so far as patients chose a convenient time rather than being given a pre-determined fixed appointment. Therefore, results should be viewed in the context of this pragmatic limitation of study design. Each patient was followed-up after undergoing gonadotoxic treatment with an average of three post-treatment visits (range 19 post-treatment visits). Mean values of the two pre-treatment semen analyses were compared with the best post-treatment semen analysis. The follow-up period is variable and depended on the rate of recovery of the sperm concentration. Furthermore, for the lymphoma and testicular cancer groups, the first and last post-treatment semen samples were also compared.
Data analysis
Statistical analysis was performed using SPSS® for Windows® (SPSS Inc, Chicago, IL). Data were analysed using Spearman's rank correlation test, MannWhitney U-test, Wilcoxon signed rank test and the Pearson 2 test. A multiple logistic regression analysis was performed using a forward selection model to adjust the existing association between prognostic factors.
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Results |
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Table Ib illustrates the subgroup analyses of semen quality. In the testicular cancer group, only the concentration and volume were significantly reduced. In the leukaemia group, only the concentration was significantly reduced. The lymphoma group revealed a significant reduction in the concentration, motility and motility grade but not the volume, while in the other malignant neoplasm group, both the concentration and motility were significantly reduced. In the benign condition group, only the sperm concentration showed a significant reduction.
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Discussion |
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In our analyses, the sperm quality in terms of density, motility and volume was significantly reduced (P<0.05) following gonadotoxic treatment for all groups (Table I). However, only the magnitude of change in concentration appears to be of clinical relevance. This suggests that the damaged or destroyed germinal stem cells may recover from an initial cytotoxic insult and maintain a reasonable sperm quality in terms of motility and motility grading, although sperm concentration remained variable. The lymphoma and leukaemia groups showed the highest incidence of azoospermia following gonadotoxic treatment, at 46 and 59% of their respective groups (Table III). On the other hand, the benign neoplasms and testicular cancer groups showed the lowest incidence of azoospermia at 16 and 12%, respectively, which may be indicative of less severe gonadotoxic treatment regimens in these conditions compared with, for instance, lymphoma.
The testicular cancer group was found to have the lowest sperm concentrations of all the disease categories before treatment (Table II). However, following cytotoxic treatment, the testicular cancer group showed the lowest level of azoospermia (12%), but the highest level of oligozoospermia (38%). The normospermia levels after treatment for the testicular cancer group were also high (50%), second only to the the benign group (61%) (Table III). The high level of oligozoospermia in these patients may be due to impaired spermatogenesis pre-treatment, and treatment with less gonadotoxic modalities might have spared them from developing azoospermia. This observation was supported by the findings of recent studies (Bahadur et al., 2002; Gandini et al., 2003
). The testicular cancer group had a significant decline in only the concentration and volume. (Table Ib).
Our finding of reduced sperm quality in testicular cancer patients confirms other studies. Patients with testicular cancer have an impaired semen quality at diagnosis which deteriorates further after orchidectomy. Previous studies have shown that 5070% of patients with testicular cancer after orchidectomy, but before cytotoxic treatments, have impaired spermatogenesis (Hendry et al., 1983; Palmieri et al., 1996
). A link between male factor subfertility and testicular cancer is also recognized (Jacobsen et al., 2000
). Reduction in sperm concentrations may be linked to disruption of embryonal programming and gonadal development (Skakkebæk et al., 2001
), elevated scrotal temperature secondary to neovascularization and HCG production by the neoplastic testicle (Berthelsen and Skakkebaeck, 1983
). Recovery of sperm function after treatment has, so far, been unpredictable (Byrne et al., 1987
; Siimes and Rautonen, 1990
), While all patients initially developed azoospermia following bleomycin, cisplatin and etoposide (BEP) chemotherapy, 48% have recovered motile ejaculated sperm after 2 years, and after 5 years this figure rises to 80% (Lampe et al., 1997
). Although the total sperm count may still be reduced, the potential for fatherhood still exists.
It was reported that impaired pre-treatment semen quality occurs in lymphoma and leukaemia patients (Botchan et al., 1997; Hallak et al., 1999
). Our previous study (Bahadur et al., 2002
) illustrated that sperm counts before gonadotoxic treatment were significantly lower in Hodgkin's and non-Hodgkin's lymphoma, and in leukaemia patients than in a healthy sperm donor population, reflecting the adverse contribution of the disease. This point receives support elsewhere (Kobayashi et al., 2001
; Rueffer et al., 2001
). However, normal semen parameters were also reported in cancer patients (Rofeim and Gilbert, 2004
).
In this study, the leukaemia and lymphoma groups fared worst following gonadotoxic treatment. There is a body of information to suggest that the nature of treatment regimens could explain some effects on the level of gonadotoxicity, and where sperm prevail, some effect on the sperm function (Reiter et al., 2002; Chapman et al., 1979
; Whitehead et al., 1982
; Anselmo et al., 1990
; Longo et al., 1997
; Viviani et al., 1985
; Van den berg et al., 2004
; Kulkarni et al., 1997
; Pryzant et al., 1993
). In our analyses, Table IIa reveals the recovery time was longest for the leukaemia and lymphoma groups.
Although leukaemia patients had the highest pre-treatment sperm concentrations (Table II), 46% of patients developed post-treatment azoospermia (Table III). As there is a high proportion of viable stem cells which are subjected to gonadotoxic agents, this results in a larger overall fall in sperm concentration. Germ cell dysfunction occurs over a short interval, as opposed to the situation in testicular cancer. This may account for the longer recovery time in this group of patients. It remains difficult to differentiate the contribution of disease and treatment on semen quality without prospective randomized controlled studies. Despite its large cohort size, retrospective analysis of the clinical information has limited our ability to answer this question completely.
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Although future options for patients may become available with regards to germ cell technology of repopulating the testes with testicular stem cells, or by generating mature sperm cells from embryonic stem cells, the safety and ethical use of these technologies should not be underestimated (Bahadur, 2004). Cryopreservation of semen prior to gonadotoxic treatment is the current preferred strategy, but testicular sperm extraction and ICSI after chemotherapy has also been employed successfully (Meseguer et al., 2003
). Caution needs to be exercised, however, in utilizing sperm obtained after cancer treatment to protect the welfare of the child (Meistrich et al., 1985
; Meistrich, 1993
; Robbins et al., 1997
; Martin et al., 1999
; Chatterjee et al., 2000
; Arnon et al., 2001
; De Mas et al., 2001
; Kobayashi et al., 2001
; Reiter et al., 2002
; Frias et al., 2003
; Codrington et al., 2004
; Deane et al., 2004
; Seli et al., 2004
). Even if sperm prevail after treatment, it is prudent practice to avoid use of these in vivo sperm for 1.52 years to enable sufficient turnover of cells to expel the mutagenic effect. These estimates may be high, and perhaps 612 months grace may be more pragmatic and realistic.
It would be most desirable in our field to have predictive tools and recognizable associations (Fossa et al., 1997; Tal et al., 2000
). In our study, we aimed to see if there were any predictors of the semen quality decline and their possible recovery after gonadotoxic treatment. It became clear that the disease category was the single most important predictor of the sperm parameters. This reflects the pathology of the disease and the nature of the gonadotoxic treatment.
As a result of our analyses on our cohort of patients undergoing gonadotoxic treatment, a number of facts and associations emerge, listed below.
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Approximately 63% of patients may develop irreversible azoospermia. The fact that all categories of patients in our cohort suffered variable levels of azoospermia, together with the unpredictable recovery of azoospermia, reinforces the notion that ejaculated sperm should be banked prior to treatment. The significant decline in overall semen parameters after gonadotoxic treatment should lead clinicians to be more proactive in recommending sperm cryopreservation before treatment. This will help obviate patient distress and medico-legal problems, and above all give each patient a sense of reassurance with the knowledge of heightened safe potential use of sperm not previously subjected to toxic therapy. On a cautionary note, our study does not provide either reassurance or caution in the clinical use of post-treatment sperm, and careful counselling especially on genetic issues must follow.
Conclusion
Patient diagnosis remains a significant factor in predicting post-treatment azoospermia. All patient categories displayed varying levels of azoospermia and oligozoospermia. Given that there was an insignificant recovery in spermatogenesis following treatment, or that azoospermia remained, it is essential to offer sperm banking before any gonadotoxic treatment. This should be allied to dedicated counselling and support to cancer patients.
Several additional observations and associations in relation to semen quality are listed further, thereby giving an insight into pre- and post-gonadotoxic treatment effects and relationships. For example, apart from those patients who experienced the worst deterioration in sperm concentration and had to wait longer than 66 months to reach their peak recovery, there appears to be no significant benefit in prolonging the post-treatment follow-up with the expectations of significant recovery, thereby adding a new clinical feature to post-treatment counselling and management of patients. Patients with lymphoma and leukaemia have a higher probability of maintaining sperm concentrations >20 x 106/ml if they escaped from developing azoospermia.. Patients with different diagnoses also exhibited different time intervals to achieve their best post-treatment sperm parameters. The recovery times between treatment and the best post-treatment semen analyses is reflected in the diagnostic category. Finally, the unproven genetic effects of cancer treatment on sperm needs to be kept in perspective.
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Submitted on October 5, 2004; resubmitted on November 4, 2004; accepted on November 19, 2004.
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