Reproductive Complications
Summary of Key Points
• Reproductive complications resulting from cancer or its treatment are expected to increase as the number of cancer survivors increases.
• The risks of infertility related to cancer therapy and the available fertility preservation options should be discussed with all patients of reproductive age before cancer therapy begins.
• Oligospermia is present in more than 50% of patients with Hodgkin lymphoma and testicular cancer.
• Prostatectomy and other pelvic surgeries are associated with erectile dysfunction; retroperitoneal dissection is associated with retrograde ejaculation.
• Erectile dysfunction occurs within 2 years after treatment in 60% to 80% of patients with prostate cancer who are treated with external beam radiation.
• The use of sildenafil has reestablished potency in a large number of patients with surgery- or radiation-induced erectile dysfunction.
• Radiation can affect testicular spermatogenesis after doses as low as 15 cGy. Ovarian function is more resistant, but the effects are age related.
• Gonadal shielding and ovarian transposition ameliorate the effects of radiation on gonadal function.
• Gynecologic surgery can have a direct impact on sexual function by altering the normal female genital anatomy.
• Alkylating agents are associated with the highest rates of infertility in men and women.
• Doses and duration of chemotherapy agents are directly associated with the risk of infertility.
• The return of menses does not indicate preservation of ovarian function.
• Cancer complicates 1 in every 1000 pregnancies.
• The highest risk of congenital abnormalities is associated with chemotherapy or radiation exposure during the first trimester of pregnancy.
• It has not yet been determined whether the use of gonadotropin-releasing hormone analogs protects ovarian function and preserves spermatogenesis.
1. You have diagnosed a premenopausal woman with stage IIB Hodgkin lymphoma (HL) with no disease below the diaphragm. She is to start therapy, which includes chemotherapy and irradiation. This patient’s risk of infertility is:
A Low; she is premenopausal and ovarian function is preserved in younger women.
B Low; current chemotherapy options for HL are less gonadotoxic, and she does not need abdominal/pelvic irradiation.
C High; she will require significant alkylating agents to achieve curable disease.
D High; she will require total abdominal irradiation, which puts her at risk of ovarian failure.
2. A 30-year-old man has been diagnosed with testicular cancer. Which of the following statements are true?
A He is at risk of infertility because of the chemotherapy he will receive.
B He is at risk of erectile dysfunction from retroperitoneal lymph node dissection.
C He should be encouraged to cryopreserve his sperm before starting any cancer therapy.
3. Which statement is true about men with prostate cancer?
A In men with radiation-induced erectile dysfunction, potency decreases over time.
B Intensity-modulated radiation therapy is associated with less erectile dysfunction.
C Robotic-assisted laparoscopic radical prostatectomy preserves sexual function.
D Sildenafil citrate has not been found to be helpful for men with cancer who have erectile dysfunction.
1. Answer: B. Previous treatment protocols for HL included regimens with procarbazine, which placed patients with HL at high risk of infertility because of the significant gonadotoxic effects of alkylating agents. Current therapy options include nonalkylating combination chemotherapy, such as Adriamycin, bleomycin, vincristine, and dacarbazine. These regimens have been associated with a lower risk of infertility because they are significantly less gonadotoxic. This patient will not need any abdominal or pelvic irradiation because her disease is above the diaphragm.
2. Answer: D. Men with testicular cancer are known to have decreased spermatogenesis at the time of diagnosis. In fact, infertile men who have low sperm quality and decreased sperm production are at higher risk of developing testicular cancer. All men who are of reproductive age and diagnosed with cancer should be made aware of the risks of infertility associated with the type of cancer therapy they may have and should be offered the opportunity to cryopreserve their sperm before therapy begins. Options to use cryopreserved sperm are varied and largely successful.
3. Answer: A. In patients with prostate cancer, it has been found that radiation-induced erectile dysfunction increases with time so that potency can be decreased years after the radiation. Although intensity-modulated radiation therapy has improved disease outcome, it is associated with increased risk of erectile dysfunction. Robotic-assisted laparoscopic radical prostatectomy has become a much more common procedure. At this time, it is not entirely clear that this procedure decreases the risk of erectile dysfunction; ongoing studies are needed, but at this time, patients should not be reassured that robotic-assisted prostatectomy will decrease this risk. Sildenafil citrate has been shown to benefit prostate cancer survivors who have erectile dysfunction from either surgery or radiation.
