GKT School of Medical Education, King's College London, London, UK.
College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
BJU Int. 2019 Jan;123(1):160-172. doi: 10.1111/bju.14455. Epub 2018 Jul 27.
The aim of the present paper was to determine the impact of testicular cancer (TC) and its treatments on fertility and to review the current management options for the infertile patient with TC, both before diagnosis and after treatment, with the aim of providing practical recommendations to update contemporary guidelines and standardize clinical practice.
Searches were conducted for relevant articles on Pubmed and Google Scholar between 2000 and 2017, with additional articles sourced from reference lists of included publications.
At time of diagnosis, 6-24% of patients with TC were reported to be azoospermic and 50% oligozoospermic. Without conducting semen analysis at diagnosis, these patients cannot be identified and may be at further risk of subfertility. Gonadotoxic therapies cause an overall decrease in male fertility by 30% and there is currently no method to predict which patients will become azoospermic after treatment. Patients with larger, more invasive tumours, however, are at greater risk of infertility from local tumour effects, and are also more likely to undergo several different type of therapy, which has further detrimental effects on conception rates. Most treatment-induced infertility recovers 2 years post-treatment, but paternity can be delayed during a couple's peak reproductive years. Semen cryopreservation remains the procedure of choice in preserving fertility, but the service is underused, with only 24% of patients banking sperm. Microdissection testicular sperm extraction (microTESE) at the time of orchidectomy (onco-microTESE) is a successful infertility treatment option for those found to be azoospermic or severely oligozoospermic at diagnosis, while microTESE may still retrieve sperm in azoospermic patients after chemotherapy.
The underutilisation of semen analysis and sperm cryopreservation results in the failure to identify the azoospermic or severely oligozoospermic patient at diagnosis who may benefit from fertility-preserving procedures, for example, onco-microTESE at the time of orchidectomy. Fertility preservation and counselling needs to be broached earlier in the TC treatment pathway and made a greater priority. Given the advances in treatment, more patients with TC are surviving and looking to return to a normal life. Preserving their future fertility plays an important role in achieving this.
本研究旨在探讨睾丸癌（TC）及其治疗对生育能力的影响，并综述 TC 患者在诊断前和治疗后的生育力管理选择，旨在为更新当代指南和规范临床实践提供实用建议。
在 2000 年至 2017 年期间，在 Pubmed 和 Google Scholar 上进行了相关文章检索，并从纳入文献的参考文献中获取了其他文章。
在诊断时，有 6-24%的 TC 患者被报道为无精子症，50%为少精子症。如果不在诊断时进行精液分析，这些患者就无法被识别出来，可能会有进一步的生育力低下风险。性腺毒性治疗会使男性生育力总体下降 30%，目前还没有方法预测哪些患者在治疗后会成为无精子症。然而，肿瘤较大、侵袭性较强的患者由于局部肿瘤的影响，更有可能不孕，而且更有可能接受多种不同类型的治疗，这对受孕率有进一步的不利影响。大多数治疗引起的不孕不育在治疗后 2 年即可恢复，但在夫妇生育高峰期，生育可能会延迟。精子冷冻保存仍然是保存生育力的首选方法，但该服务的使用率较低，只有 24%的患者进行了精子冷冻保存。在睾丸切除术（onco-microTESE）时进行精曲小管睾丸精子提取（microTESE）是诊断为无精子症或严重少精子症患者的一种成功的不孕不育治疗选择，而在化疗后无精子症患者中，microTESE 仍可能提取精子。
由于未能在诊断时识别出无精子症或严重少精子症患者，错过了可能受益于生育力保护的患者，例如在睾丸切除术时进行 onco-microTESE，因此精液分析和精子冷冻保存的利用率较低。在 TC 治疗途径中更早地进行生育力保存和咨询，并将其作为更重要的优先事项。鉴于治疗的进展，越来越多的 TC 患者存活下来，并希望恢复正常生活。保留他们未来的生育能力在实现这一目标中起着重要作用。
