Late effects: Men’s health problems

The male reproductive system

The male reproductive system contains many structures and is controlled by the pituitary gland in the brain. The testicles are located in the scrotum (the loose pouch of skin that hangs behind the penis). The testicles are made up of Leydig cells (cells that produce the male hormone - testosterone) and germ cells (cells that produce sperm). When a boy enters puberty, the pituitary gland in the brain releases two hormones (FSH and LH) that signal the testicles to begin producing sperm and testosterone. As puberty progresses, testosterone causes deepening of the voice, enlargement of the penis and testicles, growth of facial and body hair, and muscular development of the body.

How can previous treatments affect the male reproductive system?

Infertility (the inability to initiate a pregnancy) can occur following certain types of surgery, chemotherapy, or radiation to the brain or testicles.

Another possible effect of therapy is testosterone deficiency, also known as "hypogonadism" or "Leydig cell failure." When this occurs, the testicles are unable to produce enough of the male hormone, testosterone. If this happens after puberty, a man will need testosterone therapy to maintain muscular development, bone and muscle strength, proper distribution of body fat, sex drive, and the ability to have erections.

What types of previous treatments increase the risk of problems with the male reproductive system?

Chemotherapy

The class of drugs called alkylators can cause infertility when given in high doses. Very high doses may occasionally cause testosterone deficiency. Examples of these drugs include busulfan carmustine, chlorambucil, cyclophosphamide, Ifosfamide, lomustine, melphalan, procarbazine and thiotepa.

Radiotherapy

Radiotherapy to any of the following areas may cause infertility.

• Testicles
• Pelvis (including iliac/inguinal/femoral, bladder, prostate, total nodal, and "inverted Y" fields)
• TBI (total body irradiation)
• Head/brain (cranial)

In addition to causing infertility, high doses of radiation to the testicles, pelvis or brain may also cause testosterone deficiency.

What monitoring is recommended?

Males whose treatment places them at risk for problems with the reproductive system should have a yearly check-up that includes careful evaluation of their hormone status. If any problems are detected, a referral to an endocrinologist (hormone specialist), urologist (specialist in the male reproductive organs) or fertility specialist may be recommended.

What can be done for testosterone deficiency?

Males with low testosterone levels may benefit from testosterone replacement therapy. Testosterone is available in several forms, including skin patches, injections, and topical gel. Your endocrinologist will determine which form of therapy is best for you.

How will I know if I am infertile?

Infertility is not related to sexual function. The only certain way to check for sperm production is to have a semen analysis performed. This test checks the appearance, movement and concentration of sperm in the semen. A semen analysis that shows azoospermia (no sperm in the semen sample) on more than one sample is an indicator of infertility. 

Infertility following radiation is likely to be permanent. However, recovery of sperm production may occur months or years after the completion of chemotherapy in some men. For others, chemotherapy damage may be permanent. It is not possible to determine if sperm production will resume, especially if chemotherapy ended only a few years prior to the semen analysis. For this reason, always assume that you can make someone pregnant unless you are absolutely sure that you cannot and use adequate contraception. Also remember that condoms remain necessary to reduce the transmission of many sexually transmitted diseases.

When should I get a semen analysis?

Any male who is concerned about fertility should have a semen analysis performed.

What if the sperm count is low?

If the results show no sperm (azoospermia) or very low sperm counts (oligospermia), the test should be repeated several times. Sperm recovery following chemotherapy may take as long as 10 years, so if you have had chemotherapy that may cause low sperm counts, it may be important to check periodically over several years. Also, men’s sperm counts vary considerably from day to day, so test results may improve if additional samples are checked after waiting a month or two.

Sperm production and quality may continue to improve as more time passes from the chemotherapy treatment. Men who have low sperm counts cannot rely on this to prevent pregnancy. Pregnancy can occur with low sperm counts. Some method of birth control must be used if pregnancy is not desired.  If pregnancy is desired, couples in whom the man has low sperm counts may benefit from assisted reproductive techniques such as Intra Cytoplasmic Sperm Injection (ICSI), a form of invitro fertilization. A consultation with an infertility specialist is helpful in order to obtain further information regarding these options.

What are my options if there are no sperm in the semen analysis?

If semen analysis shows no sperm (azoospermia), and children are desired, see an infertility specialist. Medical advancements dealing with male infertility are continually being made.

Other good options for males who produce no sperm include donor insemination or adoption. Donor insemination (DI) uses sperm from another male, either from a known or anonymous donor. DI results in pregnancy with a child that is biologically related only to the mother. Additional options may include adoption of a biologically unrelated child or child-free living.

How do I use the sperm cryopreserved before treatment started?

Options for using banked sperm depend on the amount and quality of material saved. Men who banked sperm prior to chemotherapy or radiotherapy will need to work with an infertility specialist, so that the cryopreserved (frozen) sperm can be used in an optimal manner.