1 Royal Free and University College Medical School, Department of Obstetrics & Gynaecology, Fertility and Reproductive Medicine Laboratories, University College Hospitals Trust, 8896 Chenies Mews, London WC1E 6HX, 2 Department of Medicine, University Street, London WC1E 6AU, 3 Institute of Urology St. Peters & Middlesex Hospital, London W1N 8AA and 4 Middlesex Hospital, Mortimer Street, London W1N 8AA, UK
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: adolescent/cancer/cryopreservation/sperm/spermaturia
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
When a patient fails to produce semen there could be rescheduling or delay in the cancer treatment. For adolescents it is natural to ask questions with regard to the settings, their maturity and what may be done to improve their chances to successfully preserve their fertility prior to the gonadotoxic treatment. These events have not previously been reported in the literature. Through our unique experience of adolescent cancer patients, their relatives and specialists, we report on this patient cohort who were unable to produce semen. This may help patients, their relatives and the numerous specialists involved in the planning of their treatment.
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The laboratory records included other information about the accompanying person and their level of participation.
Statistical analyses were performed using the Statistical Package for Social Science (version 6.1). Data are expressed as mean (SD) unless otherwise stated. Association of categorical variables was compared using the 2-test with continuity correction. The probabilities of failing to produce a semen sample by patients (non-producers) while attending the unit for fertility preservation in the accompanied and unaccompanied group were estimated and compared, as described previously (Morris and Gardner, 1988
). A P-value of < 0.05 was accepted as being statistically significant.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The total number of accompanied and unaccompanied patients attending their treatment session was 64 and 174 respectively (Table I); 29.7% (19/64) of the accompanied patients were non-producers while 8.0% (14/174) of the unaccompanied patients failed to produce a semen sample before their treatment (
2 = 16.58, P < 0.001). The relative risk (RR) of not producing a semen sample was higher in the accompanied group of patients than in the unaccompanied group (RR = 3.7, 95% confidence interval: 2.06.9).
|
An accompanied patient (aged 18 years) suffering from leukaemia failed to produce a semen sample on his first visit but was successful in his attempt on a subsequent unaccompanied visit to our clinic [sperm count = 3x106 ml, motility = 50%, progression = 1/4 (4 = highest, 1 = lowest), semen volume = 2.5 ml].
The youngest patients (n = 3) who were unable to produce semen were diagnosed as: Ewings sarcoma (11 year old); lymphoma (11 year old) and osteosarcoma (12 year old), and each patient was accompanied by one or both parents. Significantly, each patient could accurately describe masturbation, ejaculation and semen consistency, and acknowledged the reason for sperm storage, during a one-to-one counselling.
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Understandably it is a sensitive topic to ask adolescent patients to provide semen (Bahadur et al., 2001). Reasons for the inability to produce semen may include the lethargy of their illness, but particularly with adolescents, shyness and immaturity may be important features. They may be too embarrassed to admit to or be known to be masturbating or have nocturnal emissions in the presence of parents or an accompanying guardian. Against this backdrop, there is unavoidable involvement of parents with regards to the recovery and welfare of the adolescent cancer patients (Bahadur et al., 2000
; Dockerty et al., 2000
). One welfare aspect concerns a common thread for both the patient and parents, and this is the fertility potential which holds promise for continuity of the family line. Failure to bank semen can therefore have much wider concerns and it is important to question further when a patient fails to produce semen.
The subject of non-production of semen has not previously been reported. In one report, 53.3% (24/45) of adolescent cancer patients appeared not to bank semen, although a detailed account of these non-producers was lacking (Muller et al., 2000). This figure contrasts with 13.9% (33/238) in our cohort who did not bank semen. From the aspect of the welfare of patients and relatives, however, such a negative event can become profoundly distressing and disturbing especially at a time of being given news of a potentially life-threatening disease. An element of failure for the patient can be lessened by analysing the urine (spermaturia analyses) (Schaefer et al., 1990
), following on from an unsuccessful or attempted masturbation. A post-masturbation urine sample is easily produced and may give the patient some sense of hope and alleviate the failure factor, whilst the demands on most laboratories are insignificant. This is also by far the least invasive of techniques when considering other options such as surgical extraction of gonadal tissue and penile vibratory stimulation and rectal electroejaculation (Schmiegelow et al., 1998
; Hovav et al., 2001
). The presence of sperm in the urine of adolescents seems to be an interesting observation since this group of patients are not expected to have weakness in their bladder neck and urethral structures, as found in those adults suffering from retrograde ejaculation. The analyses of urine after unsuccessful attempts to produce semen led to a successful attempt at sperm cryopreservation in one patient in our cohort, although the uptake of this technique was low (12.1%).
Adult patients storing sperm are more likely to be accompanied by a partner, who has a direct reproductive and sexual involvement. In contrast, and unique to fertility preservation, adolescent cancer patients are likely to be accompanied by persons of a platonic or nurturing relationship when attending a sperm banking facility. Whilst noting the negative association of sperm banking success with the accompanied group, the presence of an accompanying person should not be seen to be a bar since 22% in the successful group were accompanied. The presence and participation of the accompanying person can be helpful, but a balance needs to be struck in relation to their continued presence just before and when the patient attempts to produce a semen sample by masturbation.
In conclusion, adolescent cancer patients who fail to produce semen should be encouraged to provide a urine sample for analysis. Importantly, practitioners should give careful attention to the presence of an accompanying adult, a factor that has not previously been commented upon, to enable a balanced and successful outcome for the adolescent patient.
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Bahadur, G. (2000) Fertility issues for cancer patients. Mol. Cell. Endocrinol., 169, 117122.[ISI][Medline]
Bahadur, G., Chatterjee, R. and Ralph, D. (2000) Testicular tissue cryopreservation in boys. Ethical and legal issues. Hum. Reprod., 15, 14161420.
Bahadur, G., Whelan, J., Ralph, D. and Hindmarsh, P. (2001) Gaining consent to freeze spermatozoa from adolescents with cancer: legal, ethical and practical aspects. Hum. Reprod., 16, 188193.
Dockerty, J.D., Williams, S.M., McGee, R. and Skegg, D.C.G. (2000) Impact of childhood cancer on the mental health of parents. Med. Ped. Oncol., 35, 475483.[ISI][Medline]
Hovav, Y., Dan-Goor, M., Yaffe, H. and Almagor, M. (2001) Electroejaculation before chemotherapy in adolescents and young men with cancer. Fertil. Steril., 75, 811813.[ISI][Medline]
Morris, J.A. and Gardner, M.J. (1988) Calculating confidence intervals for relative risks (odd ratios) and standardised ratios and rates. Br. Med. J., 296, 13131316.[ISI][Medline]
Muller, J., Sonksen, J., Sommer, P., Schmiegelow, M., Petersen, P.M., Heilman, C. and Schmiegelow, K. (2000) Cryopreservation of semen from pubertal boys with cancer. Med. Ped. Oncol., 34, 191194.[ISI][Medline]
Schaefer, F., Marr, J., Seidel, C, Tilgen, W. and Scharer, K. (1990) Assessment of gonadal maturation by evaluation of spermturia. Arch. Dis. Child., 65, 12051207.[Abstract]
Schmiegelow, M.L., Sommer, P., Carlsen, E., Sonksen, J.O.R., Schmiegelow, K. and Muller, J.R. (1998) Penile vibratory stimulation and electroejaculation before anticancer therapy in two pubertal boys. J. Pediat. Hematol. Oncol., 20, 429430.[ISI][Medline]
Submitted on March 1, 2001; resubmitted on May 13, 2002; accepted on June 12, 2002.