1 Introduction

It is generally agreed that sperm banking should be routinely offered prior to the administration of any anti-neoplastic treatment to post-pubertal males following a diagnosis of cancer. It may also be required following a number of other diagnoses (e.g. some renal or rheumatoid conditions) as well as prior to some pelvic surgery or in cases of gender dysphoria. However, since there are over 5,000 new diagnoses of cancer in the United Kingdom each year in males of reproductive age (up to the age of about 44 years old), the majority of men banking their sperm will be following referral from an oncologist. This has led to the development of specific oncofertility pathways for men (and women) who need to preserve their fertility and these represent a number of significant challenges for health professionals in sperm banks and assisted conception units if a timely and effective service is to be provided. This chapter will review the latest thinking on how to provide an effective and efficient service, as well as consider the management of sperm banks in the longer term.

2 Referring Men for Sperm Banking

UK Clinical guidelines [1,2], and those from elsewhere in the world [3,4], each recommend that sperm banking should be a routine part of the care of all post-pubertal males prior to any anti-neoplastic treatment associated with a diagnosis of cancer. However, even with these guidelines in place, the evidence suggests that only a minority of men (<30%) actually bank sperm (although there are significant country-to-country differences in this as table II of reference [5]). There are two main reasons to explain this low uptake.

The first relates to the behaviour of oncologists themselves. For example, there are several studies showing that even with comprehensive guidelines in place, some oncologists simply do not raise the subject of fertility or make the patient aware that sperm banking is available and might be a good idea. This is for a number of different reasons which include the following: (i) difficulties in communication or embarrassment felt by the oncologist in raising the topic; (ii) lack of awareness about the local sperm banking facilities available and the pathway by which men might be referred; (iii) assumptions about the man’s needs based on a perception of his family structure, his age or his sexual orientation and (iv) the need to start treatment quickly and a view that saving a man’s life is preferable to preserving his fertility if by arranging sperm banking there will be a delay in him starting cancer treatment.

The second relates to the behaviour of men themselves when presented with a choice between starting treatment immediately or delaying treatment by a few days in order to bank sperm. There is no doubt that for some men this will be a difficult decision and in a prospective study of 91 newly diagnosed men who were offered the opportunity to bank sperm by their oncologist, the decision to decline the offer was specifically related to their quality of life scores [6] regardless of diagnosis and stage of disease. This suggests that some men may miss out the opportunity to bank sperm, because at the time of diagnosis they are feeling unwell. In this context, interview data [7] has shown that men’s decisions to bank sperm need to be seen in the context of their experience prior to diagnosis and the fact that many had been to their General Practitioner many times before their symptoms had been taken seriously. Many men reported that at diagnosis they had been overwhelmed by the amount of information they had received and all emphasised the role of the oncologist in organising sperm banking and making it just part of the cancer journey, alongside other routine appointments such as blood tests, chest X-Rays and CT scans.

Whilst the literature says that some oncologists can be seen as barriers to sperm banking, others show that they are essential to facilitate the process. Therefore, in running an effective fertility preservation service for men, it is recommended that strong links are developed between reproductive medicine specialists and key oncologists in the local area to make sure everyone is clear about the services available and the optimum methods of referral [8]. It is suggested that named link nurses be identified who can help to cross the boundary between the two specialties and who can help with the coordination of specific patients or serve as a conduit of information when protocols change.

3 Sample Procurement and Storage

Once a patient is identified who wishes to bank sperm, the next challenge is how to obtain a suitable specimen for cryopreservation. A common concern of health professionals is whether in oncology patients there will be sufficient sperm to bank because (i) the patient is very young, (ii) their disease may have compromised testicular function or (iii) they are too unwell to become sufficiently sexually aroused to produce an ejaculate by masturbation.

With regard to the first of these concerns (male age) the evidence is clear that sperm production is a relatively early event in puberty, with spermatogenesis commencing at an average of 13.4 years of age (range 11.7–15.3) [9]. This means that only a brief assessment of pubertal development is required before a referral can be considered. What is more problematic is whether young males of this age are sufficiently sexually mature to understand what is required of them in terms of giving the necessary consent and also the need for them to masturbate in a medical environment. The issue of providing a safe space for sample production and the provision of erotic material to facilitate sexual arousal is discussed in more detail in this chapter, but needless to say a young age is not necessarily a barrier to sperm banking once puberty has started.

Second is the issue of to what extent the patient’s disease may have compromised his testicular function, thereby limiting the number or quality of sperm that can be recovered from an ejaculate and frozen. Whilst there is some evidence to suggest that the incidence of azoospermia in men attending for sperm banking is higher than is seen in the general population, there is on average sufficient sperm in the majority of men for use in assisted conception at a later date. For example, a recent study of 3,062 men banking sperm at the Hammersmith Hospital (London, UK) found that up to 11% had cryptozoospermia (where sperm were only seen in the centrifuged pellet) [10].

Finally, for those males who are unable (or unwilling) to produce a semen sample by masturbation (or where an ejaculate proves to be azoospermic), techniques of surgical sperm retrieval can be used if there is sufficient time to do so before the start of anti-neoplastic treatment and the male is well enough to undergo the procedure. Sometimes, sperm recovery can be undertaken at the time of other surgical procedures (e.g. orchidectomy) to avoid unnecessary delays and minimise the number of surgical procedures and outpatient visits.

However, the majority of males (>90%) are able to successfully produce ejaculates for sperm banking by masturbation and so consideration should be given to the clinical environment and other logistical arrangements which can be put in place for them to achieve this. For example, since men banking sperm at the time of diagnosis have a relatively poor understanding of the process and are doing it as part of a package of care being organised by their oncologist [7], to suggest that they are dealt with like all other male patients attending an assisted conception unit may not be ideal. Whilst some sperm banks are run as stand-alone services, others are inevitably linked to an in vitro fertilisation (IVF) unit and so consideration should be given to the fact that men with cancer do not necessarily identify as fertility patients at this stage, as well as the fact that they may not be in a serious relationship and may wish to attend alone, or with a friend, a healthcare professional, parent or guardian. Therefore a separate waiting area may be preferable, as might a separate consultation style and separate information sheets specifically tailored to sperm banking as part of oncology treatment.

A common area for discussion among health professionals is the provision of a suitable space for the collection of masturbatory ejaculates and whether or not the provision of erotic material is a good idea or not. With regard to the former, very little has been written about the needs of oncology patients and it is suggested that this is developed by understanding the needs of users through normal service evaluation activities (e.g. focus groups and/or questionnaires). However, with regard to the provision of suitable erotic material, several papers have been written to suggest it is a useful thing to provide [11]. Not only does it seem to improve ejaculate quality but it also increases the probability of obtaining a sample. However, those providing sperm banking services in the United Kingdom should be aware that it may be unlawful to provide erotica for use by males under the age of 18 years, although evidence suggests that minors would prefer to bring their own material with them [12]. Those working outside the United Kingdom should check their local laws with regard to the minimum age for the provision of erotic material (if it is allowed at all).

Finally, once an ejaculate is obtained, there are a fairly standard series of protocols for sperm cryopreservation (although it is likely that each laboratory will have its preferred method). Unfortunately, there is often significant loss of sperm viability during the freezing process [13], although for most men sufficient numbers of viable sperm do remain to allow sperm to be utilised during intracytoplasmic sperm injection (ICSI). However, sperm banks should monitor their ongoing sperm freezing rates by conducting regular post-thaw analysis of samples. Moreover, this information should ultimately be given to each patient so that they can know what to reasonably expect should they need to use their samples in treatment. This information can be revisited during post-treatment follow-up consultations as part of the suite of information which is discussed and revisited several times during the years that sperm is kept in storage.

4 Post-treatment Fertility Monitoring

Once anti-neoplastic treatment has ended, all men with banked sperm should be offered the opportunity to undergo regular semen analysis so that any long-term effects can be established and they can make their decisions about family planning and contraception appropriately. However, the literature suggests that men are often reluctant to engage with fertility monitoring programmes provided by sperm banks and often do so only when establishing a new relationship or planning to start a family [7]. Moreover, data from interviews suggest that a common deterrent to attending for semen analysis was men’s anxiety about the result, with most preferring not to know if their semen quality was poor. Yet, ironically, information about recovered fertility is welcomed, even in men who did not want any more children, because it contributes to restored feelings of masculinity. Other reasons for non-attendance for post-treatment semen analysis have been investigated [14] and include the following: (i) the lack of treatment side effects such as sickness and diarrhoea; (ii) a bad experience of the sperm banking process and (iii) having negative attitudes to disposal of the banked samples. These data suggest that there are complex physiological reasons why men might not accept invitations for semen analysis and a lack of response from them should not be taken as indicating that they are not interested in their banked sperm.