After a radical prostatectomy, a man will not ejaculate again. Remember that semen is produced by the seminal vesicles, mostly, but also by the prostate, and that only a bit of semen is actually sperm travelling from the testicles via the vas deferens. During a radical prostatectomy, both the prostate and the nearby seminal vesicles are removed. So there is no semen to carry the sperm down the urethra and out the penis during orgasm. Consequently, the sperm cannot make it out of the body.

Radiation therapy also impairs fertility. The radiated prostate cells and seminal vesicles tend to produce semen that cannot transport the sperm very well. There is also chronic scarring of the prostate and ejaculation ducts, which means that most men do not ejaculate semen at all three to five years after external beam radiation treatment. Another risk is that sperm, which is produced and stored in the testicles, can be damaged, although this side effect is becoming increasingly rare with more targeted radiation therapy. 

Chemotherapy and hormone therapy can also cause temporary or permanent infertility. However, these treatment options are usually used when prostate cancer has spread or recurred, in other words, when the cancer has metastasized or after treatments for localized prostate cancer, such as surgery or radiation, have already been undertaken.

So what is the recommendation? Men should plan for the distinct possibility that they will be sterile after prostate cancer treatment. If they are interested in fathering children, they should bank sperm prior to therapy.

Banking Sperm
The process of banking sperm is simple. In a private room, a man ejaculates into a sanitized cup. His semen sample is tested to determine its sperm count and how many sperm are actively swimming. At the same time, it will be tested for viruses and sexually transmitted diseases, such as hepatitis and HIV. (Remember that confidentiality will be respected.)

Then, the semen will be placed in a container and frozen (cryo-preserved) at very low temperatures, so it can be thawed and used in the future. Most facilities say that samples can be stored for ten years or longer, although we don’t know how long sperm can be frozen and used. Doctors estimate that about fifty percent of the sperm will die during the freezing process, however. So it is useful to plan on giving three or so samples before treatment.

To ensure that his sperm count is as high as possible and that he has adequate semen volume, a man should abstain from ejaculating for three or so days prior to banking sperm. It is a balancing act, however, because old sperm do not function as well as new sperm; they tend to swim poorly. So longer periods of abstinence can affect sperm quality.

Extracting Sperm After Treatment
Even though a man cannot ejaculate after surgery or radiation therapy for prostate cancer, he will still produce sperm as long as his testicles are functioning normally. This fact leaves open the option of having sperm extracted for in-vitro fertilization, if a man wants to father a child after treatment.

The process of sperm extraction, also called sperm retrieval or sperm aspiration, is usually done with a local anaesthetic in an outpatient or office setting. It takes about thirty minutes to one hour. There are currently three main methods of extraction: MESA (microsurgical epididymal sperm aspiration), PESA (percutaneous epididymal sperm aspiration), and TESE/TESA (testicular sperm extraction/testicular sperm aspiration).

In MESA, an incision is made in the scrotum, and, under microscopic control, sperm is removed from the epididymis, tightly coiled tube-like structures located behind the testes that conduct sperm away from the testicles. The microscope helps physicians locate sperm.

PESA also collects sperm from the epididymis. The difference is that the extraction is done without microscope examination of the collection site and through the skin (hence percutaneous, which means done or effected through the skin). So, whereas individual epididymal tubules are sampled for sperm with MESA, multiple epididymal tubules are sampled blindly with PESA.

In TESE/TESA, a small amount of tissue is extracted from each testicle using a little needle. Sperm is extracted from this tissue. The procedure is performed after a patient has been injected with local anaesthetic, so the scrotum and testes are numb.

Fertilization
Sperm collection is often done in conjunction with intracytoplasmic sperm injection (ICSI), a type of in-vitro fertilization procedure that also incorporates collecting eggs from a man’s female partner.

Remember that, even with the use of frozen sperm collected prior to treatment, in-vitro fertilization is the procedure that a couple will use to conceive a child. Sperm that is extracted or frozen is usually not good enough for artificial insemination (which places sperm directly into a woman’s reproductive tract) or natural conception. So physicians use in-vitro fertilization, the joining of a man’s sperm and a woman’s egg in a laboratory dish “outside the body” or “in vitro.” Usually intracytoplasmic sperm injection (ICSI), which involves injecting the sperm directly into the egg, is the preferred procedure.

For more information:
Mulhall, John P., Saving Your Sex Life: A Guide for Men with Prostate Cancer (Chicago: Hilton Publishing Company, 2008).