Male fertility preservation

Preserving fertility is an important consideration for men and boys who may undergo treatments or face conditions that can impair their ability to have biological children in the future. This section outlines indications for intervention, evidence-based approaches for male fertility preservation, including current techniques, and emerging therapies.

 

What are the options?

A discussion about fertility and consideration of fertility preservation options should happen for individuals with conditions that may affect their fertility and this should take place before starting any treatment that could harm fertility. The choice of
fertility preservation method depends on individual factors such as fertility risk, age, pubertal status, existing sperm production, and the urgency of treatment.

 

Common options include:

• Puberty and adulthood

Semen Cryopreservation (Sperm Banking): Collection of sperm via ejaculation, followed by freezing and long-term storage.
Electroejaculation (EEJ): Under anaesthesia, electrical stimulation helps produce an ejaculate in patients unable to ejaculate naturally (e.g. spinal cord injury).
Testicular Sperm Extraction (TESE): Surgical procedure to retrieve sperm from testicular tissue in cases of azoospermia or when ejaculation is not possible.

• Prepuberty:

Testicular Tissue Cryopreservation: For prepubertal boys who are not yet producing sperm. Age-appropriate counselling and involvement of guardians are critical. This approach would require subsequent treatment to use the cryopreserved testicular tissue to generate sperm and therefore is considered experimental (see below).

• All ages:

Radiation Shielding: Placement of protective shield(s) over the testes during radiotherapy to limit exposure.

 

Experimental Strategies

Emerging technologies may offer future options. Currently, these are considered experimental and are offered under clinical trial protocols.

• Techniques using cryopreserved testicular tissue:

Spermatogonial Stem Cell (SSC) transplantation
Testicular tissue re-transplantation
In vitro maturation of germ cells from frozen testicular tissue
Testicular organoid culture

• Other experimental techniques:

Pharmaceutical protection against chemotherapy-induced gonadotoxicity

 

What are the indications?

Fertility preservation may be indicated for individuals with:

• Malignant conditions:

Testicular cancer
Leukemia and lymphoma
Brain tumors or other solid cancers requiring chemotherapy (especially alkylating agents) and/or radiotherapy (particularly pelvic or cranial)
Haematopoietic stem cell transplant (HSCT; often referred to as bone marrow transplant)

• Non-malignant conditions:

HSCT for benign disease e.g. sickle cell disease or aplastic anaemia
Autoimmune diseases treated with cytotoxic drugs (e.g., lupus, multiple sclerosis)
Genetic syndromes affecting spermatogenesis (e.g. Klinefelter syndrome)
Trauma or surgical interventions to the testes or reproductive tract that may disrupt sperm production or delivery

• Personal or professional reasons, including:

Transgender individuals (assigned male at birth) planning gender-affirming hormone therapy or orchiectomy (removal of the testicles)
People in high-risk professions (e.g. military deployment)

 

Guidance and Considerations

• Timing: Counselling regarding fertility and discussion of options for fertility preservation should be arranged before starting gonadotoxic therapy.
• Pubertal status: Assessment of pubertal status is very important. Post-pubertal males can often provide a semen sample for sperm banking. Pre-pubertal males are limited to testicular tissue cryopreservation, which remains experimental.
• Consent and counselling: Individuals (or guardians) must understand risks, possible side effects, success rates, costs, alternatives and legal/ethical considerations of storage and future use. Multidisciplinary teams should support informed decision-making.
• Documentation: Consent, disclosure of storage duration, usage rights, and options for disposition of specimens (e.g., in the event of death) should be clearly documented.
• Success rates and limitations: Sperm freezing is well-established and cryopreserved sperm can be stored indefinitely; experimental techniques such as testicular tissue freezing are still considered research.