Prostate cancer is the second leading cause of cancer deaths in American men, just behind lung cancer. While prostate cancer is a serious disease by any measure, most men diagnosed with it will survive it (98% overall 5-year survival). But in many cases, therapy for prostate cancer will be needed and surgical or radiation treatments are largely sterilizing from a fertility point of view.
You may ask, if prostate cancer occurs mainly in older men, why is fertility even an issue? Well, for me there are two good reasons: The first is that more younger men are being diagnosed with prostate cancer, and the second is that American men are now postponing fatherhood as they never have before. Worldwide, the incidence of prostate cancer has steadily increased in men ages 15 to 40 years at about 2% per year for the last 30 years. To boot, younger patients with prostate cancer frequently have more advanced cancers, need more therapy, and have worse outcomes than older men. It appears that these earlier prostate cancers are more likely to be hereditary in nature and are associated with mutations in BReast CAncer gene 2 (BRCA-2), long associated with breast cancer. Add to this the fact that over the last 50 years, births to fathers aged 40 years or older have doubled, currently accounting for 10% of all births, and you might see what I am seeing: a potentially rockier road to fatherhood.
If you really like to plan ahead, then one great way to protect your future fertility is to consider banking your sperm before there’s a threat to your health. This is a solution for all occasions and all cancers and is a tried-and-true method of fertility preservation that has been around for over 50 years. What’s new is that now it can be done not only at traditional brick and mortar sperm banks but also using mail-in “online” sperm banks. Alternatively, in situations in which low-grade prostate cancer can be “followed” with active surveillance and not directly “treated” up front, fertility can often be preserved, and family building pursued. Whether or not your prostate cancer can be safely followed involves having important discussions with your urologist and requires due diligence in tracking it on your part.
If the cancer requires treatment that involves removal of the prostate, receiving radiation or hormonal therapy, then infertility is the rule. Fertility-wise, surgical removal of the prostate is akin to having a vasectomy: sperm is still made in the usual numbers but the outflow into the ejaculate is blocked. In these situations, fairly simple sperm aspiration or retrieval procedures are effective but require assisted reproduction (IVF-ICSI) for success. External beam radiation therapy to the prostate does not block sperm outflow but can impair sperm production through the scattering of X-rays into the nearby testicles which are very sensitive to ionizing radiation. In this case, procedures such as sperm mapping can locate small, residual pockets of testicular sperm and enable men to undergo sperm aspiration or retrieval procedures along with IVF-ICSI to become fathers. Internal radiation given by brachytherapy is far less toxic to sperm production and can allow for relatively normal fertility following treatment. This may also be true of other more “focal” (as opposed to whole gland) treatments for prostate cancer such as high-frequency ultrasound (HiFU) or cryotherapy (freezing).
Androgen ablation or testosterone reducing hormonal treatments for prostate cancer generally and globally “turn off” sperm production completely while they are taken. However, if given intermittently or for a limited time (say less than 3 years) there is a chance that some sperm production may resume once hormones have been discontinued, making fatherhood possible.
It’s heartwarming to know that fertility is achievable in the vast majority of men with prostate cancer. This is certainly true before treatments are given and still true afterwards as well. As the old proverb goes: Difficult roads often lead to beautiful destinations.
Photo by Tara Winstead