|Year : 2009 | Volume
| Issue : 1 | Page : 22-24
Testicular sperm retrieval at the time of bilateral radical orchiectomy
Anmar M Nassir1, John E Grantmyre2, Rekha Gupta3
1 Department of Surgery, Um Al-Qura University, Makkah, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
2 Department of Urology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax NS, Canada
3 Department of Pathology, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax NS, Canada
|Date of Submission||02-Feb-2009|
|Date of Acceptance||23-Feb-2009|
|Date of Web Publication||17-Mar-2009|
Anmar M Nassir
PO Box-126 143, Jeddah, 21352
| Abstract|| |
A new indication for testicular tissue cryopreservation is discussed here. We evaluate the feasibility of testicular sperm extraction during bilateral orchiectomy for testicular cancer. A 26-year-old man with a history of right orchidopexy presented with primary infertility. Tests revealed left varicocele and oligospermia. He underwent varicocelectomy but was lost to follow-up. Nine months later, he presented with right-sided solid testicular swelling. Ultrasound examination confirmed the finding of possible neoplasm and revealed contralateral intratesticular lesion. Since the patient turned azoospermic, no semen sample could be cryopreserved. Permanent histopathological sections revealed bilateral classical seminomas. On processing the fresh healthy looking specimen, normal-looking viable sperm were obtained. Future attempts at in-vitro fertilization with intracytoplasmic sperm injection should be possible. This method has been described in metachronous testicular cancer, but to our knowledge, we are the first to use it in synchronous bilateral testicular tumors.
Keywords: Azoospermia, bilateral seminoma, male infertility, orchidopexy, synchronous testicular cancer, TESE
|How to cite this article:|
Nassir AM, Grantmyre JE, Gupta R. Testicular sperm retrieval at the time of bilateral radical orchiectomy. Urol Ann 2009;1:22-4
| Introduction|| |
Infertility is a common problem worldwide. Approximately 15% of couples are infertile. An abnormal male factor is involved in approximately one half of cases.  Although unusual, serious underlying disease can be diagnosed in infertile patients. Compared to normal population, men with abnormal semen characteristics have higher risk of subsequent testicular cancer. ,
Bilateral testicular tumors represent a rare event and account for 1% of all testicular neoplasms,  and are devastating, particularly to the unfathered patient.
| Case Report|| |
An otherwise healthy looking 26-year-old logger presented to infertility clinic at the Queen Elizabeth II hospital with severe oligospermia. His sperm concentration was 600,000/cc with occasional motile sperm in a total volume of 4.3cc. He had a history of a right cryptorchidism that was corrected at the age of ten. On examination, he had grade III left varicocele with an underlying atrophic testicle. The right testicle had a normal volume without any evidence of varicocele. His left-sided varicocele was so evident to expect any benefit from ultrasound examination, not usually conducted in similar cases. The patient underwent left varicocelectomy using a subinguinal approach with the aid of optical magnification. Recovery was uneventful. The patient was lost to follow-up at three months postsurgery for repeat semen analysis.
Nine months postsurgery, the patient presented with a right testicular discomfort and a three-month history of swelling. Repeat semen analysis revealed azoospermia, with a volume of 6cc, and no sperm seen even after centrifugation. On examination, the right testicle was diffusely enlarged, firm, and nontender. The left testicle was normal. Testicular ultrasound revealed a 5-cm solid hypoechoic lesion virtually replacing the right testicle, and bright small echogenic foci throughout the testicle, confirming our presumptive diagnosis of neoplasm. Multiple small hypoechoic lesions, the largest one measuring 15mm, were seen peripherally in the left testicle. Radiologically, the findings were suggestive of multiple foci of seminoma. Repeated semen analysis, done just before surgery, showed azoospermia.
An immediate bilateral exploration was performed and intraoperative frozen sections revealed bilateral classical seminomas. A bilateral radical orchiectomy was performed. A large piece of testicular tissue was retrieved from the grossly normal-appearing remaining tissue of the left testicle. This tissue was placed in human tubal fluid (HTF) and transferred immediately to the in-vitro fertilization (IVF) lab. Using the standard technique, the specimen was minced with a scalpel to free the sperm from the testicular tissue. It revealed low concentration of normal viable testicular sperm of normal morphology. Using the standard freezing technique the specimen was centrifuged and cryopreserved for possible future use.
Permanent histopathological sections revealed bilateral classical seminomas [Figure 1]. No other germ cell tumor components were noted. Sections of the epididymis and spermatic cord were free of tumor. No vascular or lymphatic invasion was seen. The left testis showed similar morphological features to the other side with an invasion of the rete testis by in situ germ cell neoplasia. Careful examination of sections away from the tumor area showed normal seminiferous tubules with evidence of spermatogenesis [Figure 2].
Postoperatively, beta HCG dropped from a preoperative value of 58 to less than 2IU/L, while the pre and postoperative AFP was within the normal range. Chest radiography and CT of his abdomen were normal. The patient was placed on testosterone replacement therapy and was referred for adjuvant radiation therapy.
Up to his last follow up in mid-2007, the patient was completely free of tumor and living a normal life. The patient has chosen not to use the cryopreserved sperm yet.
| Discussion|| |
The discovery of a life-threatening cancer and the prospect of treatment that may further compromise fertility can be catastrophic to young patients. Those who have bilateral disease have a brief opportunity for sperm preservation.
Not only are testicular neoplasms found more commonly among infertile population, but also impaired spermatogenesis is seen more frequently among patients with testicular tumors. In approximately 50% of testicular cancer patients subnormal sperm densities are found on presentation and before treatment.  Apparently this is not counterbalanced by the contralateral testis. The reason for this is poorly understood. 
Is this due to abnormal bilateral testes to start with? Or is it because of a defect in the cooling mechanism due to cancer. Whether or not spermicidal substances are produced by the cancer cells is an issue that is yet to be established. Furthermore, eventual treatment of testicular tumor by radiation or chemotherapy is well-known risk on spermatogenesis. 
Of those rare bilateral testicular tumors, 15-37% occur synchronously in both testicles, while the remaining will present metachronously. , Many patients with bilateral tumors have not yet fathered children.
Although in a few selected cases, a conservative organ-sparing approach to bilateral testicular tumor has been mentioned in some studies,  the risk of recurrence is well recognized. ,
In our case, we performed testicular sperm retrieval from the fresh orchiectomy specimen for cryopreservation. Future attempts at IVF with intracytoplasmic sperm injection should be possible. This method has been described in unilateral , or metachronous testicular cancer,  but to our knowledge, we are the first to use it in synchronous bilateral testicular tumors.
In case of infertile patient with cryptorchid testicle the increased risk of testicular cancer should be borne in mind.  Previous reports of infertile patients with a history of nonobstructive azoospermia and cryptorchidism who underwent sperm extraction were incidentally found to have a testicular seminoma. 
Often men with bilateral tumors are virtually or truly azoospermic and many have not banked sperm prior to therapy. Even for those who have, the sperm is often of poor quality that cannot be cryopreserved for future use. Testicular sperm often have high viability and there is no disadvantage to attempts in retrieving sperm from areas of the testicle not involved with tumor. Fortunately, assisted IVF technique has improved tremendously. The microsurgical insertion of sperm directly into the egg itself (intracytoplasmic sperm injection (ICSI)) has resulted in a significant enhancement of fertilization in IVF for the couple with male factor infertility. In situations similar to our case, the above technique should be discussed with the patient and considered as a priority before any other alternatives. This choice is very valuable in communities where sperm donation is not an option.
| Conclusion|| |
This case suggests that patients undergoing a bilateral radical orchiectomy can benefit from testicular extraction of sperm for cryopreservation. Currently, sperm thus retrieved are used individually for IVF/ICSI and one would not expect that contamination with potentially malignant testicular cells would be clinically relevant.
| References|| |
|1.||Raman JD, Nobert CF, Goldstein M. Increased incidence of testicular cancer in men presenting with infertility and abnormal semen analysis. J Urol 2005;174:1819-22. [PUBMED] [FULLTEXT] |
|2.||Jacobsen R, Bostofte E, Engholm G, Hansen J, Olsen JH, Skakkebaek NE, et al. Risk of testicular cancer in man with abnormal semen characteristics: Cohort study. BMJ 2000;321:789-92 [PUBMED] [FULLTEXT] |
|3.||Mancini M, Carmignani L, Gazzano G, Sagone P, Gadda F, Bosari S, et al. High prevalence of testicular cancer in azoospermic men without spermatogenesis. Hum Reprod 2007;22:1042-6. [PUBMED] [FULLTEXT] |
|4.||Che M, Tamboli P, Ro JY, Park DS, Ro JS, Amato RJ, et al. Bilateral testicular germ cell tumors: Twenty-year experience at MD Anderson Cancer Center. Cancer 2002;15:1228-33. |
|5.||Sakamoto H, Oohta M, Inoue K, Fuji K, Fukagai T, Yoshida H. Testicular sperm extraction in patients with persistent azoospermia after chemotherapy for testicular germ cell tumor. Int J Urol 2007;14:167-70. [PUBMED] [FULLTEXT] |
|6.||Kliesch S, Behre HM, Jürgens H, Nieschlag E. Cryopreservation of semen from adolescent patients with malignancies. Med Pediatr Oncol 1996;26:20-7. |
|7.||Gandini L, Sgrò P, Lombardo F, Paoli D, Culasso F, Toselli L, et al. Effect of chemo- or radiotherapy on sperm parameters of testicular cancer patients. Hum Reprod 2006;21:2882-9. |
|8.||Fossε SD, Chen J, Schonfeld SJ, McGlynn KA, McMaster ML, Gail MH, et al. Risk of contralateral testicular cancer: A population-based study of 29,515 U.S. men. J Natl Cancer Inst 2005;97:1056-66. |
|9.||Yossepowitch O, Baniel J. Role of organ-sparing surgery in germ cell tumors of the testis. Urology 2004;63:421-7. [PUBMED] [FULLTEXT] |
|10.||Gomes PJ, Rustin GJ. Attempted preservation of one gonad in patients with bilateral germ cell tumours. Clin Oncol (R Coll Radiol) 1996;8:397-9. [PUBMED] |
|11.||Heidenreich A, Hφltl W, Albrecht W, Pont J, Engelmann UH. Testis-preserving surgery in bilateral testicular germ cell tumours. Br J Urol 1997;79:253-7. |
|12.||Carmignani L, Gadda F, Gazzano G, Ragni G, Paffoni A, Rocco F, et al. Testicular sperm extraction in cancerous testicle in patients with azoospermia: A Case Report. Hum Reprod 2007;22:1068-72. [PUBMED] [FULLTEXT] |
|13.||McCallum B, Choi P, Schlegel M. Testicular sperm extraction at the time of radical orchiectomy for cancer in a solitary testis. J Urol 1998;159:163. |
|14.||Richiardi L, Pettersson A, Akre O. Genetic and environmental risk factors for testicular cancer. Int J Androl 2007;30:230-40. [PUBMED] [FULLTEXT] |
|15.||Novero V Jr, Goossens A, Tournaye H, Silber S, Van Steirteghem AC, Devroey P. Seminoma discovered in two males undergoing successful testicular sperm extraction for intracytoplasmic sperm injection. Fertil Steril 1996;65:1051-4. [PUBMED] |
[Figure 1], [Figure 2]