How is sperm cryopreservation performed and what are the indications for a reproductive‑age male before chemotherapy, radiation, hormonal therapy, testicular surgery, or elective vasectomy?

Sperm Cryopreservation: Standard of Care for Fertility Preservation

Sperm cryopreservation via masturbation is the established standard of care and must be offered to all reproductive-age males before chemotherapy, radiation, hormonal therapy, testicular surgery, or elective vasectomy. 1

Primary Indications

All reproductive-age males facing the following treatments require immediate sperm banking discussion:

• Chemotherapy - particularly alkylating agents (90% azoospermia risk) and procarbazine-containing regimens 1
• Radiation therapy - testicular doses as low as 2 Gy cause follicle loss; sterilizing doses range from 14-16 Gy depending on age 1
• Testicular surgery - any procedure with risk of compromising spermatogenesis 2
• Hormonal therapy - exogenous testosterone and other gonadotoxic hormonal treatments 2
• Elective vasectomy - for men desiring future fertility options 3

How Sperm Cryopreservation is Performed

Collection Method

Primary approach: Ejaculation via masturbation - this is the most established, cost-effective technique with extensive outcome data 1

Alternative collection methods when masturbation fails:

• Testicular sperm extraction (TESE) or microsurgical TESE (microTESE) 1
• Electroejaculation under sedation 1
• Post-masturbation urine sample collection 1

Sample Requirements

• Collect 3 samples ideally with 48-hour abstinence intervals between collections 4
• Minimum target: Total motile count >5 million per sample 4
• Multiple samples maximize future assisted reproductive technology (ART) success 4
• Cost: Approximately $1,500 for three samples stored for 3 years, with additional annual storage fees 1

Timing Considerations

Critical: Banking must occur BEFORE any gonadotoxic treatment begins 1, 4

• Sperm DNA integrity is compromised as early as 1-2 weeks after chemotherapy initiation 4
• Even urgent cancer treatment should not preclude banking - the process takes only days 4
• Multiple samples can be collected over several days if time permits 4

Special Populations

Adolescents and Young Men

• Spermarche occurs at approximately 13-14 years - once sperm are present, age does not affect sperm quality 1
• Adolescents may be more successful collecting samples without parental presence at the sperm bank 1
• Issues of informed consent and embarrassment must be addressed sensitively 1

Men with Poor Baseline Semen Parameters

Poor pre-treatment semen quality is NOT a contraindication to banking 4

• Even severely oligospermic or compromised samples can achieve pregnancy via intracytoplasmic sperm injection (ICSI) 1, 5, 3
• Modern ART requires minimal sperm quantities for success 1, 4
• Men with advanced disease and systemic symptoms may have reduced sperm quality even before treatment, but should still bank 1

Azoospermic Men

• If no sperm in ejaculate after excluding hypogonadotropic hypogonadism, proceed to TESE/microTESE 1
• Surgical sperm extraction yields similar fertilization, pregnancy, and live birth rates compared to ejaculated sperm 2

Outcomes and Success Rates

Pregnancy rates with cryopreserved sperm are comparable to fresh sperm:

• ICSI with frozen sperm: 50% pregnancy rate (15 pregnancies from 30 cycles in one series) 6
• IVF typically allows 37% live delivery rate per cycle, closely related to female partner age 2
• Epididymal and testicular sperm retrieval show similar success rates 2

Utilization data:

• 27% of men recover normal sperm production 6 months post-treatment 6
• 8.7% of frozen samples are eventually discarded (55% due to natural pregnancy, 28% due to sperm recovery, 18% due to patient death) 6

What NOT to Do: Ineffective Approaches

Hormonal gonadoprotection is explicitly contraindicated and should NOT be offered 1, 5

• GnRH analogs/antagonists with or without androgens are ineffective 1
• Hormonal therapy does not preserve fertility with highly sterilizing chemotherapy 1, 5
• Does not accelerate spermatogenesis recovery compared to controls 1, 5
• Exogenous testosterone must be avoided in all men seeking fertility - it suppresses spermatogenesis 2, 5

Adjunctive Measures

Gonadal shielding during radiation therapy should be applied when anatomically feasible to reduce testicular radiation exposure 1

Critical Pitfalls to Avoid

• Never delay banking to "see how treatment goes" - DNA damage occurs immediately after treatment initiation 4
• Never assume banking can occur after starting treatment - this window closes rapidly 4
• Never withhold banking due to poor baseline parameters - even minimal sperm can succeed with ICSI 4
• Never offer hormonal gonadoprotection as fertility preservation - it is ineffective 1, 5
• Never use exogenous testosterone in men desiring fertility - it causes azoospermia 2, 5

Counseling Requirements

All reproductive-age cancer patients must receive oncofertility counseling as early as possible in treatment planning, regardless of disease type or stage 1

• Provide written information and online resources whenever possible 1
• Refer immediately to fertility specialist for all interested patients 1
• Document fertility preservation discussion in medical record 4
• No absolute threshold exists for gonadotoxicity risk - consider every patient at potential risk 1

Safety Considerations

No increased risk of genetic abnormalities or cancer in offspring from cryopreserved sperm, cancer history, or fertility interventions (excluding hereditary syndromes and in utero chemotherapy exposure) 1

Contraception required during and for at least 6 months after gonadotoxic treatment completion 2