Azoospermia and Spermatogenesis in Testicular Cancer

Francesco Rocco, Elisabetta Finkelberg, Isabella Oliva, Gabriele Cozzi, Franco Gadda
European Urological Review, 2010;5(2):42-5
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Abstract

A correlation between infertility and testicular cancer is described by many authors. Studies show that testicular carcinoma in situ and spermatogonial differentiation share histological similarities. According to some authors, male infertility and testicular cancer, together with hypospadias and undescended testis, are linked by a dysgenesis syndrome (the so-called testicular dysgenesis syndrome). Endocrine disrupters and genetic and environmental factors seem to be possible causes. Moreover, diagnosis of testicular cancer is frequently made during male infertility evaluation. Cryopreservation of sperm is the first choice for preservation of fertility before treatment of testis cancer. In cases of azoospermic patients with testicular cancer, when sperm cryopreservation is not possible the only remaining option is testicular sperm extraction, even in cancerous testis during orchiectomy. Recent studies have showed the feasibility of the procedure. The authors will review such topics.
Keywords
Testis neoplasm, azoospermia, male infertility, testicular sperm extraction (TESE), orchiectomy, semen cryopreservation
Disclosure The authors have no conflicts of interest to declare.
Received: September 30, 2010 Accepted November 26, 2010
Correspondence: Franco Gadda, Via della Commenda, 15, Padiglione C Riva, IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico, 20121 Milano, Italy. E: franco.gadda@policlinico.mi.it

Even though testicular cancer accounts for only 1% of all tumours in males,1 it is the most common malignancy in males between 15 and 34 years of age.1,2 Its incidence ranges from about 1/100,000 in Asian and African/African-American populations to 9.2/100,000 in Denmark. The worldwide incidence of testicular cancer has doubled over the last 40 years.3 A clear trend towards an increased incidence in the majority of industrialised countries in North America, Europe and Oceania, has been described.4 Over the past 50 years, nearly all European countries (Belgium, France, Germany, Ireland, Italy, The Netherlands and the Scandinavian, Baltic and Slavic countries) have witnessed an increase in this disease.1 Ninety-five per cent of all tumours of the testis are germ-cell neoplasms, of which 50% are seminomas and the remaining 50% non-seminomas. Seminomas develop on average 10 years later compared with non-seminomatous germ-cell tumours: the incidence of latter peaks at 27 years, while that of seminomas peaks at 35 years.3

Male Infertility and Testicular Cancer Risk
Fertility is defined as the ability of a sexually active couple not using contraception to achieve pregnancy within one year.5 An adverse trend in male reproductive health has been observed in many countries in recent decades.6 The reasons for this include:

  • the increasing incidence of testicular cancer;4
  • low and probably declining semen quality in many regions of the world;7 and
  • high and possibly increasing frequencies of undescended testis and hypospadias.8,9

Epidemiology identifies some risk factors for testicular cancer, such as:10–12

  • undescended testes;
  • hyperoestrogenism during foetal development (increased maternal age, decreased parity);
  • prematurity;
  • cryptorchidism;
  • chromosomal aberrations;
  • family history;
  • genetic polymorphism in genes involved in testicular function;
  • high intake of cheese and milk products;
  • high intake of red meat and fat;
  • environmental exposure to oestrogen-like substances (hormonal disruptors); and
  • a diet low in fruits and vegetables.

A report suggests that paternity is associated with a reduced risk of testicular cancer,13 as is hyperandrogenism, which has been postulated to have a protective effect.14

Testicular cancer is one of the three most common malignancies of children and young adults.10 It requires treatments that can result in infertility, hypogonadism and retrograde ejaculation.10 Carmignani et al.,15 in a series of 560 infertile patients, found focal testicular lesions in 1.4% of men, of which 0.4% were germ-cell tumours. Small testicular lesions in infertile patients were frequently Leydig cell tumours.16

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