When parents hear the words, “your son has cancer,” fertility preservation may be the last thing on their minds. But before chemotherapy begins, before one beam of radiation is delivered, pediatric urologists at Cincinnati Children’s make sure that families know their options – including testicular tissue cryopreservation (TTC).

TTC involves extracting tissue with spermatogonial stem cells (SSCs) from the prepubertal testicle prior to cancer therapy and freezing them for later use. The technology to utilize cryopreserved testicular tissue does not yet exist for humans, although some experimental therapies have been promising in animal models. Cincinnati Children’s recently began offering the procedure as part of an investigational protocol whose main focus is to study the feasibility of TTC and assess overall patient satisfaction.

TTC is one component of the Cincinnati Children’s Comprehensive Fertility Care and Preservation Program, a collaboration of subspecialists in gynecology, oncology, urology and pathology. Established in 2009, it was one of the first programs in the United States to focus on fertility preservation in patients receiving intensive therapies for pediatric cancers. “Today, more than 80 percent of these patients survive at least five years after diagnosis, and many grow into adulthood,” says Andrew Strine, MD, a pediatric urologist and co-director of the Comprehensive Fertility Care and Preservation Program. “Future fertility can be of great importance to long-term quality of life and should not be overlooked during the treatment planning process. We offer a fertility consult to every family that is dealing with a cancer diagnosis or facing a bone marrow transplant for any other reason, such as aplastic anemia. We want to make sure they understand the potential damage caused by gonadotoxic therapy, as well as the risks, strengths, limitations and science behind their fertility preservation options.”

Greater risk to males

In male children and adolescents with cancer, the risk of infertility is greater than it is for their female counterparts due to the relative chemo- and radiosensitivity of the testis. Sperm cryopreservation is still the gold standard for fertility preservation for males who can provide an adequate sperm sample. But it is not an option for pre-pubertal patients, and not desirable for others because of personal or religious beliefs. “Our TTC team, which includes pediatric urologists, advanced practitioners, a nurse navigator, pathologists and ethicists, helps parents work through the logistical, financial and ethical considerations related to the decision to pursue TTC,” Strine says. “It’s critical that parents understand the experimental nature of this procedure and the costs that may be involved in storing and eventually using the preserved tissue.”

If a patient or family opts for TTC, the biopsy often is coordinated with other surgical procedures (such as central line/port placement) to minimize the anesthetic risk and expedite the initiation of therapy. Most of the harvested tissue is sent to an independent cryopreservation company where it is frozen and stored for future use. A smaller tissue specimen is sent to a basic research laboratory at the University of Pittsburgh that is testing TTC technologies. Scientists throughout the United States are exploring the potential of several therapeutic strategies, including transplantation of SSCs into the testis, autologous grafting and xenografting of testicular tissue and maturation of testicular tissue in culture.

A team effort 

Following cancer therapy, specialists with the Comprehensive Fertility Care and Preservation Program offer evaluations of gonadal damage, as well as fertility consults for families whose children did not undergo a preservation procedure prior to therapy. It is this kind of innovative and comprehensive approach that garnered the program a Clinical Team Achievement Award in 2017. The award, bestowed by Cincinnati Children’s, recognized the program’s commitment to “redefining the standard of care for patients receiving therapies that potentially compromise reproductive health.”

Cincinnati Children’s began offering an investigational protocol for testicular tissue cryopreservation in 2017.