Semen quality at diagnosis, cryopreservation utilization, and reproductive outcomes in testicular cancer: a longitudinal cohort study

Paternity rates among testicular cancer survivors are reduced. The patient journey, from fertility preservation at diagnosis to attempted paternity or use of assisted reproductive technologies (ART), contains two key gaps in the literature. While baseline semen impairment is well recognized, the relationship between disease stage, tumor pathology, and semen quality remains inconsistent. In addition, prior studies have largely excluded sex-cord stromal tumors, lacked healthy comparators, and rarely performed pathology-specific analyses within the same clinical stage. Reported paternity rates vary widely (6-21%), yet real-world data on ART utilization and live-birth outcomes remain limited. We conducted a retrospective cohort study (2017-2023) at a single tertiary academic referral center within a healthcare system that provided full coverage for sperm cryopreservation for 5 years and ART for up to 2 live births. Primary outcomes included baseline semen parameters by tumor histology and clinical stage, pathology-specific comparisons within each stage, and post-treatment utilization of cryopreserved sperm. Secondary outcomes were ART pregnancy and live-birth rates. The semen parameters were compared with those of healthy sperm donor candidates. The cohort included 126 men (mean age 36.6 ± 10.9 years; 83 seminoma, 35 non-seminoma, 8 sex-cord stromal tumors). Compared with 100 healthy donor candidates, testicular cancer patients demonstrated significantly impaired baseline semen quality across all parameters except volume (all p ≤ 0.01). Post-thaw semen quality was further reduced, with lower motility rates (17.5% vs 44.1%) and total motile counts (1.1 vs 7.8 million), highlighting greater motility and total motile count loss following cryopreservation. Sex-cord stromal tumors exhibited the poorest semen parameters. Semen quality did not differ by stage overall; pathology-specific differences were observed only in stage II disease, favoring non-seminoma tumors (p ≤ 0.05). Overall, 69% (n = 91) elected sperm cryopreservation. Among those, the median number of vials initially frozen was 15 (IQR 10-18), with a mean of 11.6 ± 4.3 vials per patient (range 1-18). During a median follow-up of 5.3 years (IQR: 3.9-6.8), only 8% (n = 7) used their vials for ART, undergoing a median (IQR) of 2.5 (1-4) cycles per couple (15 cycles recorded among 6 of 7 couples; cycle count missing for one couple), resulting in 12 pregnancies and an overall live-birth rate of 67%: IUI: 2/2, 100%, IVF: 6/10, 60%. Testicular cancer significantly impairs semen quality, with important variation by tumor pathology rather than stage. These findings underscore the need for accurate counseling: fertility preservation often enables future use primarily through IVF and supports banking multiple vials to mitigate freeze-thaw losses.