Sperm Freezing for Fertility Preservation

Fertility Preservation is not just for cancer patients.

by Justine Witzke, PhD, MPH, July 15, 2024

Sperm freezing (cryopreservation) for fertility preservation allows individuals to store their gametes for future use, providing the potential for genetic parenthood even after undergoing treatments that may affect fertility. Sperm freezing is a well-established procedure in which semen is combined with cryopreservation media and stored in vials in liquid nitrogen. Liquid nitrogen is neither flammable nor combustible and is not reliant on electricity to maintain temperature. There is no known upper limit to how long semen samples can be stored in liquid nitrogen; there are case reports of previously frozen sperm being used decades later. It is expected that about 50% of the sperm in the initial sample will survive the freezing and thawing process.

Fertility preservation can be particularly important for individuals facing oncologic treatments like chemotherapy, surgery, or radiation, gender-affirming care, organ transplantation, bone marrow transplantation for indications such as sickle cell disease or thalassemia, other potentially gonadotoxic treatments or medications, such as testosterone replacement therapy or finasteride (Propecia), prior to vasectomy, or paternal age-related risks, any of which can impair fertility.

Oncology

The American Society of Clinical Oncology has published clinical practice guidelines recommending fertility preservation be offered to cancer patients in 2006, with updates in 2013 and 2018. Chemotherapies, immunotherapies, radiation, and surgery all may pose risks to future fertility. Wonderfully, it is well-established that pursuing fertility preservation has additional emotional benefits, as it is an indicator of optimism and future-thinking from the oncologist. Over the last 20 years, counseling of cancer patients regarding the potential impact of their treatment on future fertility has become standard of care and has allowed many cancer survivors to become parents of genetically-related children.

Gender-affirming care

Fertility preservation is an important consideration for transgender individuals undergoing hormone therapy or surgical transition procedures, as these treatments may impact future fertility and coming off of hormone therapy in the future may be far from desirable. Transgender women who have not undergone orchiectomy (removal of the testes) may opt for sperm banking before starting hormone therapy allowing preservation of their sperm for future use in assisted reproductive technologies (ART). Utilization of fertility preservation services prior to gender-affirming care remains low.

Organ transplantation

Immunosuppressants (anti-rejection drugs) may affect sexual health and reproductive potential. For some individuals, therapeutically appropriate doses of immunosuppressants will have detrimental impact on spermatogenesis leading to infertility. For others, sexual function may be impacted. There are limitations to the research available in this area and further investigation should be pursued, but patients should speak with their providers about the potential impact on future fertility and consider fertility preservation  

Bone marrow transplantation (BMT)

Among other indications, a diagnosis aplastic anemia, certain leukemias, certain lymphomas, congenital neutropenia, thalassemia, or sickle cell disease may result in treatment with bone marrow transplantation. Prior to BMT, the patient undergoes conditioning with chemotherapy and/or radiation which result in a very high likelihood of infertility. Fertility preservation can be of the utmost importance for patients likely to undergo BMT if a future genetic child may be desired.

Medications

Patients should consider inquiring with the prescribing provider about any potential on future fertility. Individuals prescribed exogenous testosterone (testosterone replacement therapy or TRT) should consider sperm freezing for fertility preservation, as there is a high likelihood of future azoospermia (no sperm in the ejaculate). Finasteride is often prescribed for hair loss, in some, but not all patients, it can have detrimental effects on semen parameters (count, motility, and morphology (shape)). Sperm freezing in advance of initiating treatment may be well-justified.

Pre-vasectomy

It is common to consider sperm freezing for fertility preservation prior to undergoing vasectomy. Family planning plans may change and/or relationship status may change after the procedure and future fertility may be desired. Pre-vasectomy sperm freezing is simpler and less expensive than attempting to reverse the vasectomy or undergoing surgical extraction of sperm from the epididymis or the testicle at a later date.

Advanced parental age

Advanced paternal age refers to the age of a man at the time of conception, particularly when he is significantly older, typically over the age of 45. While fertility declines with age in men and women, advanced paternal age has been associated with certain risks and implications for the offspring. Advanced paternal age is associated with decreased sperm quality, including lower sperm count, decreased motility, and increased DNA damage in sperm. This may lead to reduced fertility and longer time to conceive. Research suggests that advanced paternal age is associated with an increased risk of certain disorders in offspring, including autism spectrum disorders, schizophrenia, bipolar disorder, and certain congenital abnormalities. Advanced paternal age has also been associated with lower birth weight and preterm birth, both of which are known to have potentially life-long impact.

Other indications for fertility preservation include professional and environmental risks such as serving in the military or working with heavy metals or significant levels of radiation. Still other individuals may benefit from fertility preservation for professional scheduling challenges, such as significant travel and the inability to attempt to conceive at ovulation.

To enhance patient autonomy and improve access to care, fertility preservation services need to be geographically available, financially attainable, and presented with cultural competency. Counseling must include what to expect, likely timelines, risks, benefits, alternatives, anticipated options for the future, implications of regulatory requirements, and the fact that fertility preservation does not guarantee having a biologic child in the future.

While it must be the responsibility of the oncologist, endocrinologist, transmedicine specialist, or other provider to educate patients on the option of fertility preservation, it neither can nor should be the responsibility of such providers to cover all counseling considerations associated with fertility preservation.

Sperm freezing typically does not require intervention or expertise of an REI or urologist, however individuals considering sperm freezing for fertility preservation still require education and counseling on options, testing, implications of outcomes, and other considerations. Therefore, it is the responsibility of the andrology laboratory to employ best practices, have sufficiently trained staff, provide adequate time for counseling, and engage with the patient’s clinical team to ensure coordination of care. As an example, given the regulatory requirements, it is imperative that there be discussion with the individual on who the likely recipient of the sperm will be- a future female partner or a gestational surrogate. If a gestational surrogate is likely, as in the case, for example, of a man in a same-sex relationship, there is specific testing and screening required by FDA and the New York State Department of Health within seven days prior to collecting the sperm.

Despite the evidence of effective fertility preservation options and improvements in the technologies over time, there remain barriers to access. Some barriers are provider hesitation to initiate the conversation or make a referral, cost, misperceptions of the time necessary to complete the procedures, and an off-putting patient experience.  It has been reported that the number one reason why patients discontinue fertility treatment before their family is complete is the patient experience; it is not a far stretch to think the patient experience has the potential to significantly impact participation in fertility preservation services. It is imperative that fertility professionals prioritize patients.

Information and services should be evidence-based, personalized, human-centered, culturally competent, fiscally feasible, and readily accessible while considering the individual, the regulatory requirements, and the clinical implications.  This is possible.

At Aligneage Fertility, our mission is to provide high-quality, equitably accessible, compassionate, and personalized evidence-based andrology services, donor screening procedures, fertility guidance, and industry-specific consulting aligned with our vision of contributing to a world in which individuals can access the experts, information, services, and technologies necessary to enhance their family building experiences.

Aligneage Fertility offers sperm freezing for any indication of fertility preservation, donor testing and screening, when indicated, as well as one-on-one consultations. The team has over 80 years of collective experience in the field and is committed to providing the highest level of care. We can help.