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Male fertility and infertility

Fertility refers to having the ability to conceive, or being able to have a child. For males, fertility means they are able to father a child through normal sexual activity. A person's fertility depends on their reproductive organs working as they should and other factors, such as when and how often they are having sex, certain hormones, and if their partner has any problems with fertility.

When a person cannot have a child, this is called infertility, or being infertile. For males, infertility means they are not able to father a child through normal sexual activity. Doctors usually consider a person infertile when they have not been able to conceive a child after 12 or more months of regular sexual activity.

Problems with fertility can also be called reproductive problems or alterations. They happen when certain hormone levels are abnormally low or high or if reproduction organs are removed or aren't working properly. Some people never find out why they are having fertility problems. Many experts believe stress and anxiety can cause changes that play a part in infertility.

People with certain types of cancer or who are getting treatment for cancer may have fertility problems. Children and teenagers who have cancer are often of special concern. You can read more about specific adult and childhood cancers in Cancer A to Z and can learn more about how fertility might be affected in How Cancer and Cancer Treatment Can Affect Fertility.

This information is for males with cancer. If you are a gay man or transgender person, please talk to your cancer care team about any needs that are not addressed here.

Why fertility problems might develop

When a couple makes (conceives) a baby, this is called conception or reproduction. When a baby is conceived naturally, a lot of things must take place for it to happen.  Any change in how an organ works or a change in a hormone that's needed for sperm development can block conception. In other words, there can be a “body system malfunction” that can change a man's fertility and affect his ability to father a child. Certain health problems, including cancer, can affect these things. Here are some things that can happen in a man:

• A tumor or other problem might block or press on an organ and cause it to not work properly.

• Hormones that are needed to help with conception can be disrupted.

• Testicles may not make healthy sperm or might make fewer or no sperm at all.

• The process of sperm ejaculation can be disrupted.

In many cases, cancer surgery or treatment can be more likely than cancer itself to interfere with some parts of the reproductive process and affect your ability to have children. Different types of surgeries and treatments can have different effects. The risk of infertility varies, depending on:

• The patient’s age and stage of development; for example, before or after puberty, in young adulthood, in older adulthood, etc.
• The type and extent of surgery
• The type of treatment given (radiation therapy, chemotherapy, hormone therapy, targeted therapy, immunotherapy, stem cell transplant)
• The dose of treatment

It’s very important to talk to your cancer care team to know how a cancer surgery or treatment that's being recommended for you may affect fertility before having the surgery or starting treatment. If these concerns aren't talked about before surgery or treatment, it's important that they are brought up as soon as possible after surgery or when treatment starts. Don't assume your doctor or nurse will ask you about fertility concerns. You might have to start the conversation yourself. Read more about talking with your health care team in How Cancer and Cancer Treatment Can Affect Fertility. You need to be sure to get enough information, support, or resources to help you deal with any doubts, feelings, and expected fertility problems.

Cancer treatments and fertility

Surgery

Surgery might be needed for a tumor that's in or near an organ, such as a testicle, or the penis, bladder, or rectum. It might also be needed for a tumor that's in or near the nervous system, such as the brain or spinal cord. These surgeries may affect a man’s fertility.

Testicular cancer surgery

The surgical removal of a testicle is called an orchiectomy. This is a common treatment for testicular cancer. As long as a man has one healthy testicle, he continues to make sperm after surgery. But some males with testicular cancer have poor fertility because the remaining testicle is not working well. For this reason, sperm banking before the testicle is removed is now recommended for patients interested in saving their fertility. This is called fertility preservation. Read more in Fertility and Hormone Concerns in Boys and Men with Testicular Cancer.

Prostate cancer surgery

Some men with prostate cancer that has spread beyond the prostate into nearby tissues may have both testicles removed to stop testosterone production and slow the growth of prostate cancer cells. This surgery is called a bilateral orchiectomy. These males cannot father children unless they banked sperm before surgery. You can learn more in Surgery for Prostate Cancer.

For men who have prostate cancer that has not spread beyond the prostate gland, surgery to remove the prostate gland and seminal vesicles is one of the treatment options. This is called a radical prostatectomy. The prostate and seminal vesicles are the body parts that together produce semen. Surgery removes the prostate gland and leaves men with no semen production and no ejaculation of sperm after the surgery. With sexual stimulation, men can still have orgasm, but no fluid comes out of the penis. Prostate surgery to remove the prostate also can damage the nerves that allow a man to get an erection, causing erectile dysfunction (ED). This means he might not be able to get an erection sufficient for sexual intercourse. You can learn more in Surgery for Prostate Cancer

Even if a patient can get an erection, if there’s no semen coming from the penis during orgasm, he cannot conceive a child through sex. The testicles still make sperm, but the tubes (vas deferens) that deliver sperm from the scrotum to the urethra are cut and tied off during removal of the prostate gland. This results in a blockage to the flow of sperm. However, even after removing the prostate gland, there still are ways to get sperm from the testicle. See Testicular sperm extraction and epididymal sperm aspiration in Preserving Fertility in Men With Cancer to learn more.

Bladder cancer surgery

Surgery to treat some bladder cancers is much like a radical prostatectomy, except the bladder is also removed along with the prostate and seminal vesicles. This procedure is called radical cystectomy. 

Because this surgery removes the bladder and prostate gland, there is no semen production and no ejaculation of sperm after the surgery. With sexual stimulation, males can still have orgasm, but no fluid comes out of the penis. Surgery to remove the bladder also can damage the nerves that allow a man to get an erection, causing erectile dysfunction (ED). This means he cannot get an erection sufficient for sexual penetration. Get more information in Bladder Cancer Surgery.

Even if you can get an erection, if there’s no semen coming from the penis during orgasm, you cannot conceive a child during sex. The testicles still make sperm, but the tubes that carry the sperm (vas deferens) are cut and tied off during removal of the bladder and prostate gland. This blocks the flowpath of sperm. However, even after removal of the bladder and prostate gland, there are ways to remove sperm from the testicle or its sperm storage area and use them to fertilize eggs.

Other surgeries

To learn more about the body parts, sex organs, and sex function discussed here, read Sex and the Adult Male with Cancer.

A few types of cancer surgery can damage nerves that are needed to ejaculate semen. They include removing lymph nodes in the belly (abdomen), which may be part of the surgery for testicular cancer and some colorectal cancers. Nerves can be damaged when lymph nodes are being removed, and this can cause problems with ejaculation. Sometimes surgery can permanently damage the nerves to the prostate and seminal vesicles that normally cause these organs to squeeze and relax to move the semen out of the body.

When these operations affect the nerves, semen is still produced, but it doesn’t come out of the penis during orgasm (climax). Instead it can flow backward into the bladder (called retrograde ejaculation) or does not go anywhere. In cases of retrograde ejaculation, medicines can sometimes restore normal ejaculation of semen.

Fertility specialists can sometimes collect sperm from males using several types of treatments including electrically stimulating ejaculation (see Electroejaculation or sperm aspiration surgery in Preserving Fertility in Men With Cancer.

Radiation therapy

Radiation treatments use high-energy rays to kill cancer cells. Radiation that's aimed directly at testicles, or to nearby pelvic areas, can affect a male's fertility. This is because radiation at high doses kills the stem cells that produce sperm.

Radiation therapy for testicular cancer

Radiation is aimed directly at the testicles to treat some types of testicular cancer and might be used to treat childhood leukemia. Young males with seminoma (a type of cancer of the testicle) may need radiation to the groin area after a testicle has been removed. The radiation is aimed very close to the remaining testicle, damaging it. Even when a man gets radiation to treat a tumor in his abdomen (belly) or pelvis, his testicles may still end up getting enough radiation to harm sperm production.

Sometimes radiation to the brain affects the hypothalamus and pituitary gland. The hypothalamus and  pituitary gland work together to produce two important hormones called LH and FSH.  These hormones are released into the bloodstream and signal the testicles to make testosterone and also to produce sperm.  When cancer or cancer treatments interfere with these signals, sperm production can be decreased and infertility can occur. 

A male may still be fertile while getting radiation treatments, but the sperm may be damaged by exposure to the radiation. For this reason, it is important to find out how long you should wait to resume unprotected sexual activity or to try for a pregnancy. Your doctor will be able to consider your circumstances and give you specific information about how long you should wait.

You can get more details about this type of treatment in Radiation Therapy.

Radiation for prostate cancer

Seed implants for prostate cancer (brachytherapy) do not give a large dose of radiation to the testicles, and many males will remain fertile or recover sperm production. However, it's important to be sure you understand important instructions to follow during and after brachytherapy, such as:

• Avoiding sexual intercourse, and for how long
• Using birth control, and for how long
• Limiting close contact with pregnant woman and children for a certain amount of time.

Radiation for prostate cancer from a machine outside the body is more likely to cause permanent infertility, even if the testicles are shielded. (See Radiation shielding in Preserving Fertility in Men With Cancer)

Chemotherapy

During puberty the testicles start making sperm, and they normally will keep doing so for the rest of a man's life. Certain chemotherapy drugs given during childhood, however, can damage testicles and affect their ability to produce sperm. Certain types of chemotherapy later in life can also affect sperm production.

Cells start out as offspring of other cells that have divided. When cells are new, they are immature and not functioning fully. Chemotherapy (chemo) works by killing cells in the body that are dividing quickly. Since sperm cells divide quickly, they are an easy target for damage by chemo. Permanent infertility can result if all the immature cells in the testicles that divide to make new sperm (spermatogonial stem cells) are damaged to the point that they can no longer produce maturing sperm cells.

After chemo treatment, sperm production slows down or might stop altogether. Some sperm production might return, but can take many years, and sometimes does not return at all.

Chemo drugs that are linked to the risk of infertility in males include:

• Busulfan
• Carboplatin
• Carmustine
• Chlorambucil
• Cisplatin
• Cyclophosphamide
• Cytarabine
• Cytosine arabinoside
• Dactinomycin
• Doxorubicin
• Ifosfamide
• Lomustine
• Melphalan
• Nitrogen mustard (mechlorethamine)
• Procarbazine
• Thiotepa
• Vinblastine
• Vincristine

Higher doses of these drugs are more likely to cause permanent fertility changes, and combinations of drugs can have greater effects. The risks of permanent infertility are even higher when males are treated with both chemo and radiation therapy to the abdomen (belly) or pelvis.

Some other chemo drugs, such as those listed here, have a lower risk of causing infertility in males:

• 5-fluorouracil (5-FU)
• 6-mercaptopurine (6-MP)
• Amsacrine
• Bleomycin
• Dacarbazine
• Daunorubicin
• Epirubicin
• Etoposide (VP-16)
• Fludarabine
• Methotrexate
• Mitoxantrone
• Thioguanine (6-TG)

Talk to your doctor about the chemo drugs you will get and the fertility risks that come with them. 

Targeted therapy and immunotherapy

Targeted therapy and immunotherapy drugs attack cancer cells differently from standard chemo drugs. Little is known about their effects on fertility or problems during pregnancy.

Males taking thalidomide or lenalidomide have a high risk of causing birth defects in a fetus exposed to these drugs, which can stay in semen for a few months after treatment ends. Oncologists recommend that males and any sexual partner who is able to get pregnant use extremely effective forms of birth control, for example a condom for the man and a long-acting hormone contraceptive or IUD for the woman.

See Targeted Therapy and Immunotherapy to learn more about these cancer treatments.

Hormone therapy

Some hormone therapies used to treat prostate or other cancers can affect hormones that help to develop sperm. Sperm production and numbers can be lower. This can affect your ability to have a child. These drugs can also cause sexual side effects, such as a lower sex drive and problems with erections, while patients are taking them. The decrease in sperm production and the sexual side effects tend to improve once these drugs are stopped.

Bone marrow or stem cell transplant

Having a bone marrow or stem cell transplant usually involves receiving high doses of chemo and sometimes radiation to the whole body before the procedure. In most cases, these procedures have the side of effect of permanently preventing a male's ability to make sperm. This results in lifelong changes to fertility.  (See Chemotherapy and Radiation Therapy for more on these parts of the transplant process.) If you'd like to learn more, see Stem Cell Transplant.