Fertility in men
Your fertility means being able to start a pregnancy. For this to happen, a woman's egg needs to be fertilised by a man's sperm.
The parts of your body that help you do this are called the reproductive system. This includes the testicles, penis and prostate gland.
The pituitary gland at the base of your brain is also important for fertility. It releases hormones (chemical messengers in the body) that control how your reproductive system works.
Your fertility depends on:
- having healthy sperm
- being able to get an erection and to ejaculate
- having the right hormone levels.
The testicles start to make and store sperm from puberty onwards. This process is controlled by hormones that are produced by the pituitary gland and testicles. The testicles make the hormone testosterone. This hormone is also important for sex drive and getting an erection.
To start a pregnancy, you will ejaculate during vaginal sex. The fluid you ejaculate is called semen. Semen is mostly made up of fluid from the prostate gland. It also contains sperm from the testicles. If one of the sperm reaches the woman's egg, the egg may be fertilised which will start a pregnancy. Some people have difficulty starting a pregnancy in this way and may need fertility treatment to help them.
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Doctors may not be able to predict how your fertility will be affected. But your planned treatment can help give an idea of your individual risk. Sometimes, it may be possible to reduce the effects of treatment on your fertility.
Treatments can affect your fertility in different ways. They can:
- stop or reduce sperm production
- cause problems with erections or ejaculation
- affect hormone (testosterone) production.
Cancer and cancer treatment can also change how you feel about sex. It is common to have problems with sex drive and getting an erection (erectile dysfunction) during or after cancer treatment.
We have more information about coping with side effects that can affect your sex life.
Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells. It can reduce or stop sperm production. This can affect fertility. This is usually temporary, but for some people it can be permanent.
The effects of chemotherapy on your fertility depend on the following:
- The drugs you have – Some chemotherapy drugs affect fertility more than others.
- The combination of drugs – Having different drugs together may be more likely to affect fertility than having a single drug.
- The dose of the drug – Higher doses of chemotherapy are more likely to affect fertility, especially if you have them before a stem cell transplant.
Sometimes it may be possible to choose a chemotherapy treatment that is less likely to affect your fertility. Your cancer doctor will tell you if this is an option for you.
It may take time for your fertility to recover after chemotherapy. Problems with sperm production should not stop you getting erections or enjoying sex.
Radiotherapy uses high-energy rays to destroy cancer cells. It can cause fertility problems by:
- affecting sperm production
- reducing testosterone
- causing problems with erections.
Your risk of infertility depends on the dose and type of radiotherapy you are getting. If you have radiotherapy to an area of the body we do not mention below, this will not cause infertility.
Types of radiotherapy that may affect fertility include:
Radiotherapy to the pelvis
Radiotherapy destroys cancer cells in the treated area. But it can also affect some surrounding healthy tissue. Radiotherapy to the pelvis can reduce the amount and quality of sperm you produce.This may be temporary or permanent. When you ejaculate, you may notice that only a small amount of fluid comes out. Or you may notice that no fluid comes out. This means you have stopped producing semen. This is called dry ejaculation.
Radiotherapy to the pelvis may also reduce the amount of testosterone you produce. This can affect sperm production, your sex drive, and your ability to get an erection (erectile dysfunction).
You can take testosterone replacement therapy (TRT) to help. This can help with erections, but it will not make the testicles produce sperm.
If you have radiotherapy directly to the testicles, it will cause permanent infertility. You may still produce semen when you ejaculate. But it will not contain sperm.
Radiotherapy can damage nerves or blood vessels to the penis. If this happens, you may have problems getting erections. You may feel embarrassed, but you should talk to your doctor if you are having problems. There are treatments that can help with this.
The radiographer may use special ‘shielding cups’ to cover and protect the testicles during radiotherapy to nearby areas. Or you may have intensity-modulated radiotherapy (IMRT). This shapes the radiotherapy beams to fit the outline of tumours more precisely. This means less damage to areas near the tumour. Your cancer doctor can explain if these treatments are suitable for you.
Total body irradiation
Total body irradiation (TBI) is radiotherapy given to the whole body before a donor stem cell or bone marrow transplant. This usually causes permanent infertility. Your cancer doctor will talk to you about this before you agree to treatment.
Radiotherapy to the brain
Radiotherapy to the pituitary gland at the base of the brain can sometimes affect fertility. The pituitary gland releases hormones called gonadotrophins. These stimulate the testicles to produce testosterone and sperm.
After radiotherapy, the pituitary gland may stop producing gonadotrophins. This may happen some months or years after radiotherapy.
If you want to start a pregnancy, your doctor may be able to give you gonadotrophin-replacement injections. These can help you produce sperm. We have more information about fertility in men after treatment.
Surgery can reduce sperm and testosterone production. It can also cause problems with erections and ejaculation. Types of surgery that can affect your fertility include:
Surgery to the testicles
Having one testicle removed (orchidectomy) for testicular cancer should not affect your fertility. But having testicular cancer may already be causing problems with sperm production. If this is still a problem after surgery, fertility treatments can help.
Having both testicles removed causes permanent infertility. This may be done if testicular cancer comes back.
Surgery to the prostate gland
Prostate cancer may be treated with surgery. If the prostate gland is removed (prostatectomy), you will still make sperm, but it will not come out through the penis. It will be absorbed back into the body.
After prostate surgery, you may also have problems with erections (erectile dysfunction) or lose interest in sex. You may feel embarrassed, but prostate cancer doctors are used to talking about these issues and can give you advice. There are treatments that can help with this.
Other surgery to the pelvic area or abdomen
Treatment for testicular cancer and some other types of cancer may involve surgery to remove lymph nodes in the tummy area (abdomen). This operation is called a retroperitoneal lymph node dissection. It can cause nerve damage that makes sperm go into the bladder instead of coming out through the penis when you orgasm. This is called retrograde ejaculation. If this happens, you pass the sperm out harmlessly in your urine (pee). New surgical techniques mean this is now less common.
Other operations to the prostate, bladder, bowel, penis or spine can damage nerves and blood vessels to the penis. This may cause problems with erections and ejaculation.
Surgery to the pituitary gland
Surgery may be used to remove a tumour in the pituitary gland. The pituitary gland is at the base of the brain. It releases hormones called gonadotrophins. These stimulate the testicles to produce testosterone and sperm.
When surgeons remove the tumour, they try to leave some of the gland. But this is not always possible. Removing the whole pituitary gland affects hormone levels, and the testicles stop producing testosterone and sperm. If you want to start a pregnancy, your doctor may be able to give you gonadotrophin-replacement injections.
Side effects can include loss of sex drive and problems getting or keeping an erection. These may improve gradually after treatment ends. This can depend on whether you have had other treatments, such as pelvic radiotherapy or surgery.
There are different ways to help improve these side effects. Your cancer or fertility doctor can give you more information about this.
Targeted therapy and immunotherapy
It is not yet known exactly what effect these treatments may have on fertility. If you are treated with a targeted therapy or immunotherapy drug, your cancer doctor can talk to you about possible risks to your fertility.
Contraception during cancer treatment
It is important to use contraception to prevent a pregnancy during cancer treatment and for a time after it. This is because some cancer treatments may damage the sperm. This can affect a baby if a pregnancy is started during treatment. Your cancer doctor will tell you how long you need to use contraception for. If you have questions about contraception, talk to your doctor or nurse.
If your fertility does recover, it is difficult to predict when this will be. This could happen without you being aware of it. If you do not want to have a baby, you should keep using contraception unless doctors tell you the infertility is permanent.
Being able to get an erection and ejaculate does not always mean you are fertile. This is because sometimes the semen may not have sperm in it. After cancer treatment, you can have your semen tested to find out if you are producing healthy sperm. Your cancer doctor or nurse will tell you how long you should wait after treatment before getting your semen tested. Getting your semen tested is the only way to know if your fertility has recovered.
Having children is an important part of many people’s lives or their future plans. It is important to talk to your cancer doctor or specialist nurse about fertility before you start cancer treatment.
Some cancer treatments are unlikely to affect your fertility. Others may cause fertility problems during treatment or for a short time afterwards. Some treatments cause long-term or permanent damage to fertility.
Your cancer doctor will explain the possible risks to your fertility. If treatment might make you infertile, your doctor should talk to you about having your sperm stored. You usually do this before your cancer treatment starts. This is called sperm banking.
If you become infertile, you may be able to use the stored sperm to have a child in the future.
Your cancer doctor can refer you to a fertility clinic straight away. This means that having your sperm stored should not delay your cancer treatment. Sometimes, cancer treatment has to start quickly. In this case there may not be time for sperm banking.
A specialist fertility counsellor will be available to support you and your partner, if you have one.
Questions for your medical team
Below are some questions you might want to ask your medical team before cancer treatment.
- How will my fertility be affected?
- Are there ways to protect my fertility during cancer treatment?
- Can I store sperm or testicular tissue?
- Should I use contraception during cancer treatment?
It can be hard to know if cancer treatment will affect your fertility or if it will return to normal after treatment. Even if you have a low chance of becoming infertile, you may be referred to a fertility doctor before you start cancer treatment. The Human Fertilisation and Embryology Authority (HFEA) has information about NHS and private fertility clinics.
The fertility doctor may advise you to store (bank) sperm. Freezing and storing sperm is a safe procedure that has been used for many years. You can store sperm if you have reached puberty and are producing sperm.
Your sperm can then be used in the future to help you and a partner try to have a baby. Your fertility doctor can talk to you about fertility treatments that may help in your situation. They will also offer you counselling or further support.
Most fertility clinics will see you before cancer treatment starts. But sometimes you may not have time to store sperm, as treatment needs to start straight away. It is usually not advised to store sperm after treatment starts. Your cancer doctor or specialist nurse can talk to you about this.
Before sperm samples are stored, you will be asked to sign a consent form that explains how your sperm will be used. The staff at the fertility clinic will talk to you about this and explain your options.
You will have a blood test, to check for infectious diseases such as hepatitis and HIV. This is standard procedure for anyone storing sperm.
Usually, you provide semen samples by masturbation in a private room in the fertility clinic. If you have a partner, they can be with you. You may find this embarrassing but the fertility clinic staff will be very understanding and will try to put you at ease.
Sometimes, it may be possible to collect a sample at home and take it to the clinic. You will need to keep the sample warm and take it to the fertility clinic soon after producing it. You can talk to your nurse or doctor about this.
If possible, you will provide 2 or 3 samples over a week. But if you can only give one sample before cancer treatment starts, that may still be enough. Your fertility doctor or nurse will tell you how many samples you need to give. You are usually advised not to have sex or masturbate for a couple of days before collecting each sample. This allows more sperm to be collected.
Some men are unable to produce samples by masturbation. But it may be possible for a specialist doctor to collect sperm from the testicle. Before they do this, you will usually have a local anaesthetic and sedation, or sometimes you have a general anaesthetic. Sperm extraction can be done in one of the following ways:
Percutaneous epididymal sperm aspiration (PESA)
The doctor passes a fine needle into the epididymis. This is a tube on the side of each testicle that stores and carries sperm. They withdraw (aspirate) fluid containing sperm using the fine needle.
Testicular sperm aspiration (TESA)
The doctor passes a fine needle into a testicle and withdraws (aspirates) fluid containing sperm.
Testicular sperm extraction (TESE)
The doctor takes tiny bits of tissue from the testicle.
The fluid or tissue that is collected is looked at under a microscope in a laboratory. Any sperm are removed, frozen and stored for future use.
Sperm extraction can be done before cancer treatment starts. It can sometimes be done after treatment if you have not had sperm stored.
For some types of cancer, you may have sperm extracted during surgery to treat the cancer. Your doctor will tell you if this is an option for you.
Urinary sperm retrieval
If you have retrograde ejaculation, your sperm and semen go into the bladder instead of out of the penis when you orgasm.
Sometimes specialists can collect the sperm from your urine (pee). They will give you a drink that makes your urine less harmful to your sperm. You will be asked to pass urine and then masturbate. After you ejaculate, you will have to pass urine again. The sperm is quickly collected from the urine, prepared and stored.
The NHS often provides sperm storage if you are affected by cancer. But in some areas of the UK, you may have to pay for it yourself. The staff at the fertility clinic will tell you what is available in your area.
Even if storage is funded, using the sperm for fertility treatment in the future may not be. This means you may have to pay for this treatment. Your doctor or nurse will give you information about costs in your area.
Sperm is usually stored for at least 10 years. If you are affected by cancer, it can be stored for up to 55 years. Your samples will be frozen and stored in a tank of liquid nitrogen. This is called cryopreservation.
Freezing testicular tissue
Your body only starts making sperm after puberty. If you need cancer treatment before puberty, you cannot store sperm.
Boys who have not reached puberty may have testicular cryopreservation as part of a research trial. This means collecting and freezing small samples of tissue from the testicles.
Researchers are seeing if the tissue can be used to produce sperm. They are also researching whether the tissue can produce sperm if it is put back into the body after cancer treatment. This research is still at an early stage. It has not been used to start any pregnancies and doctors do not fully know the risks involved. Very few centres in the UK offer this.
Worrying about your fertility may seem especially hard when you are already coping with cancer. You may find it helps to talk things over with your partner, family or friends. If you prefer to talk to a counsellor, your GP or cancer doctor can help to arrange this. Many hospitals also have specialist nurses who can offer support, and fertility clinics will have a counsellor you can talk to.
Talking to other men in a similar position may help you feel less isolated. Macmillan’s Online Community is a good place to start. You can also talk things over with our cancer support specialists free on 0808 808 00 00.
Below is a sample of the sources used in our fertility information. If you would like more information about the sources we use, please contact us at email@example.com
Human Fertilisation and Embryology Authority. Code of practice. 8th edition. October 2009 (updated October 2017).
National Institute for Health and Care Excellence (NICE). Fertility problems: assessment and treatment. CG156. February 2013 (updated September 2017).
Royal College of Nursing. Fertility preservation: clinical professional resource. 2017.
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Chief Medical Editor, Professor Tim Iveson, Consultant Medical Oncologist.
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