Impacts of the COVID-19 pandemic on Chinese assisted reproductive technology institutions and human sperm banks: reflections in the post-pandemic era

OBJECTIVE

The COVID-19 pandemic has been the most serious public health emergency encountered in modern assisted reproductive technology (ART) development. In order to identify lessons learned, this study reviews the effect of the pandemic on ART institutions and human sperm banks in China, and summarizes the experiences and reflections of Chinese scholars post-pandemic era.

METHODS

This review is based on multiple consensus statements on the COVID-19 pandemic issued by Chinese experts as well as current national regulations and principles in ART institutions and human sperm banks to document the current situation of ART services in China, describe the impact of the pandemic on these services, and offer Chinese reflections on worrying issues in the post-pandemic era.

RESULTS

China reached one million ART cycles in 2016, and there are currently 540 ART medical institutions and 27 human sperm banks, with 540 licensed for AIH, 91 for AID, 415 for conventional IVF and ICSI and 85 for PGT. Of these, only 4 institutions carry out 10,000 cycles or more annually, and the proportion of institutions with less than 1,000 cycles has reached 66%, which means that a considerable number of ART institutions are still not saturated. As a consequence of the COVID-19 pandemic, 63.6% of ART providers and 95.5% of human sperm banks suspended operations. By the end of May 2020, China, as an early country affected by the pandemic achieved a national resumption rate of ART medical services of 99.2% and that of human sperm banks of 100.0%. Reports from the first and largest human sperm bank in China showed that qualification, semen concentration and sperm viability rates measured at primary screening have significantly decreased post-pandemic. Much like in other countries, Chinese experts developed a consensus on prevention and control measures during the pandemic. In principle, all ART activities should be suspended during acute phases of infection spread. Chinese scholars highlight that attention should be paid to young patients with fertility requirements during and after COVID-19, and emphasize the importance of fertility evaluation and clinical intervention. In addition, couples should be reminded that during ART treatment, disinfectants should not be used excessively to minimize risks of damaging the reproductive system, gametes and zygotes. At the same time, timely and reasonable guidance for tackling negative emotions from stress response is needed to provide reassurance and to avoid irrational fear and excessive stress. Seminal parameters should be re-examined 2 months after SARS-CoV-2 vaccination, and ART treatments recommenced if no abnormalities are detected.

CONCLUSIONS

Given the growing frequency of outbreaks of global infectious diseases in recent years, ART institutions and human sperm banks should pay attention to improving their prevention and control capabilities. To a certain extent, decisions and measures adopted in China during COVID-19 pandemic are worthy of recognition and acceptance. Chinese scholars have discussed, proactively responded to and understand the key issues surrounding ART development during the pandemic with the aim of contributing to the substantial progress and healthy development of ART services in the world.

[Efficiency of sperm donation: An analysis of 440 qualified sperm donors in Chongqing Human Sperm Bank]

OBJECTIVE

To analyze the efficiency of sperm donation by qualified donors and provide some experience for improving the success rate of sperm donation in human sperm banks.

METHODS

This study included 440 qualified sperm donors in Chongqing Human Sperm Bank from April 2015 to June 2019. We analyzed the general information about the donors, the causes of failed sperm donation and the results of semen bacterial culture.

RESULTS

Among the 440 qualified donors, 11 (2.50%) did not donate sperm, 28 (6.36%) were excluded because of frequent failures to donate, 397 (90.2%) completed all the procedures of sperm donation, and 4 (0.91%) failed to undergo HIV test six months after the last donation. The 397 donors that fulfilled the procedures donated sperm for 2 965 person-times, of which 2 159 (72.8%) were qualified and 806 (27.2%) unqualified for substandard semen quality (n = 684 ［23.1%］), semen volume <2 ml (n = 33 ［1.11%］), abnormal seminal liquefaction (n = 14 ［0.47%］), or positive semen bacterial culture (n = 75 ［2.53%］).

CONCLUSIONS

Substandard semen quality is the main factor affecting the efficiency of sperm donation. The staff of the human sperm bank should pay adequate attention to the first reception of and communication with the donors, dispel their worries, enhance health care guidance, prevent pollution and improve the success rate of sperm donation.

Sperm banking for fertility preservation: a 20-year experience

OBJECTIVE

Sperm banking is an effective method to preserve fertility, but is not universally offered to males facing gonadotoxic treatment in the United States. We compared the disposition and semen parameters of cryopreserved sperm from individuals referred for sperm banking secondary to a cancer diagnosis to those of sperm from men banking for infertility reasons.

STUDY DESIGN

We performed a retrospective cohort study that reviewed 1118 records from males who presented to bank sperm at Washington University between 1991 and 2010. We collected and analyzed demographics, semen parameters, and disposition of banked sperm.

RESULTS

Four hundred and twenty-three men with cancer and 348 banking for infertility reasons attempted sperm cryopreservation in our unit during the specified time period. The most prevalent cancers in our cohort were testicular (32%), lymphoma (25%), and leukemia (11%). Patients with leukemia had the lowest pre-thaw counts and motility. Most cancer patients (57%) who banked elected to use, transfer to another facility, or keep their specimens in storage. The remaining samples were discarded electively (34%) or following death (8%). Overall semen parameters were similar between the cancer and infertility groups, but demographics, ability to bank a sample, azoospermia rates, length of storage, current banking status, and use of banked sperm differed significantly between the two groups.

CONCLUSIONS

The majority of cancer patients who banked survived their cancer and chose to continue storage of banked samples. Cancer patients were more likely than infertility patients to use or continue storage of banked samples. Our study provides evidence that sperm banking is a utilized modality of fertility preservation in patients with a myriad of cancer diagnoses and should be offered to all men facing gonadotoxic therapies. Further work is needed to determine where disparities in access to sperm banking exist to improve the potential for future fertility in these males.

Sperm banking: use and outcomes in patients treated for testicular cancer

OBJECTIVE

To identify the frequency that sperm banking was used by men being treated for testicular cancer at our institution, and to characterize the differences between men choosing to bank sperm or not, and outcomes in terms of after-treatment pregnancies.

PATIENTS AND METHODS

A questionnaire addressing sperm banking and fertility was administered to men treated for testicular cancer at our institution between 1994 and 2004; the results were evaluated statistically.

RESULTS

Overall, 31 of 129 (24%) respondents had banked sperm. Of these, two had used their banked sperm to father a child, and 12 had had children naturally. Men who banked sperm were a mean of 10.3 years younger (P < 0.001) and less likely to have children at the time of diagnosis (P < 0.025) than men choosing not to bank sperm. The cost of banking sperm was reported to include a mean fee of US dollars 358 (median 300, range 0-1000), and a mean annual maintenance fee of US dollars 243.86 (median 300, range 0-1200).

CONCLUSIONS

Only a minority of men in this study chose to bank sperm (24%). Among those who did, the use of banked sperm was low (<10%), and many men could have children without using banked sperm. Given the relatively high costs of sperm banking and the low rate of sample use, patients should be counselled on the costs and benefits of sperm banking before treatment for testicular cancer.

Sperm banking in adolescent cancer patients

BACKGROUND

Semen cryopreservation is a widely available method of maintaining fertility in male cancer patients. However this facility is not always used.

AIMS

To identify the barriers to successful sperm banking in a group of adolescent and young adult patients.

METHODS

Questionnaires were administered to 55 patients aged 13-21 years who had received potentially gonadotoxic therapy between 1997 and 2001 and had been offered sperm banking.

RESULTS

Forty five questionnaires were completed; 67% of respondents were able to bank sperm. Those who had been unsuccessful were younger and described higher levels of anxiety at diagnosis and greater difficulty in talking about fertility. They also described less understanding of sperm banking at the time of diagnosis.

CONCLUSION

Most adolescent cancer patients who have been offered fertility preservation are able to bank sperm. Younger patients may be helped by the provision of high quality information and more open discussion of the technique.

Twenty Years Experience with Semen Cryopreservation in Testicular Cancer Patients: Who Needs It?

PURPOSE

To evaluate the role of semen cryopreservation (SCP) in the fertility saving management of testicular cancer (TC) patients, treated at the Norwegian Radium Hospital between 1983 and 2002.

PATIENTS AND METHODS

422 of 1388 newly diagnosed TC patients had SCP All patients were followed up for post-treatment paternity.

RESULTS

During the 20 years study period, by 2002 an increasing percentage of patients had pre-treatment SCP, reaching 43% after 1994. Twenty-nine (7%) of the 422 patients with SCP had used their frozen semen for assisted reproductive techniques (ART) at least once to achieve fatherhood. Pregnancies were achieved in 16 of these patients' partners, but two of these pregnancies ended in abortions. 67(17%) of 393 men with SCP fathered at least one child without use of frozen semen. The comparable figures for those without SCP were 205 out of 966(21%). Twenty years after orchiectomy the cumulative incidence of first post-treatment fatherhood was 47% for the 393 patients who had SCP but did not use it for ART, and 34% for the 966 patients without SCP (p=0.12).

CONCLUSION

If offered, about 50% of the young and middle-aged patients newly diagnosed with TC are interested in pre-treatment SCP. Though our study reveals that a considerable number of TC patients referred to SCP, achieve fatherhood without the use of frozen semen, the psychological impact of pre-treatment cryopreservation is undeniable. Furthermore, for some TC survivors ART with cryopreserved sperm offers the only chance of post-treatment paternity.

Sperm cryopreservation before cancer chemotherapy helps in the emotional battle against cancer

BACKGROUND

Sperm cryopreservation before cancer chemotherapy is available for young patients with cancer. However, few patients bank their sperm. The authors evaluated by questionnaire the psychological impact of sperm cryopreservation.

METHODS

The authors cryopreserved the sperm of 111 patients with cancer for free at the Yokohama City University (Yokohama, Japan). For the current study, questionnaires were mailed to 66 patients whose sperm had been cryopreserved. Fifty-one patients (77.3%) with testicular carcinomas (n = 24), leukemia or malignant lymphoma (n = 19), or other cancers (n = 8) answered the questionnaire. The average age at collection and the period of sperm cryopreservation were 30.1 +/- 6.0 (mean +/- standard deviation) and 3.3 +/- 2.2 years, respectively.

RESULTS

Many patients were informed of the deleterious effects of cancer chemotherapy and worried about infertility in the future. However, only half of the patients banked their sperm on their own initiative. Other patients followed their physician's instruction. Eighty percent of patients replied that sperm cryopreservation helped in the battle against cancer. Sperm banking especially was found to encourage every patient who banked sperm on their own initiative. After cancer chemotherapy, 70% of patients wanted to have a child. However, 60% of patients were worried about infertility in spite of having their sperm cryopreserved. No patients wanted to use cryopreserved sperm for fathering children if their spermatogenesis was restored. Sperm cryopreservation invigorated many patients with cancer after cancer treatments. The majority of patients recommended sperm cryopreservation to other cancer patients.

CONCLUSIONS

Sperm cryopreservation encouraged young patients with cancer during and after cancer treatment. It should be recommended for all young patients with cancer. However, sperm cryopreservation did not eliminate their fear of infertility.

[Requests for utilization of a semen bank among oncological patients. Semen cryopreservation prior to chemotherapy, radiotherapy and surgery]

OBJECTIVES

Oncological therapies, either surgery, radiotherapy or chemotherapy, may cause irreversible subfertiliy/infertility. Both chemotherapy and radiotherapy have cytotoxic effects on gametogenesis and there are not preventive alternatives currently available. The objective of this article is to review current criteria for semen cryopreservation and its usefulness as a method for preservation of fertility in patients with cancer.

METHODS/RESULTS

We reviewed a large group of recent original articles and systematic reviews on the issue with a common feature: evaluation of fertility status after oncological therapy.

CONCLUSIONS

Every male patient in fertile age who could wish future fatherhood should be offered the option to storage cryopreserved semen samples before starting oncological therapies, with the exception of patients with azoospermia at the time of diagnosis.

Normal semen parameters in cancer patients presenting for cryopreservation before gonadotoxic therapy

Similar sperm qualities in men with and without cancer were found. Patient and physician awareness and early referral for sperm banking are essential in preserving fertility potential in men with malignancies.

Semen cryopreservation from oncological patients: the Italian experience

The aim of the study is to summarize official data on semen cryopreservation for oncological patients in Italy. The first private semen bank for oncological patients in Italy was founded by Colpi in 1983 in Milan. In 1987, the first public semen bank was established in "Macedonio Melloni" Hospital (Milan) by Ragni. Normal semen samples are usually present in only 40% of oncological patients. The rate of semen sample use for assisted reproduction techniques is similar to international data (5%). At present, semen cryopreservation is possible only in about 20 Italian centers.

Fertility after cancer: a prospective review of assisted reproductive outcome with banked semen specimens

OBJECTIVE

To examine the outcome of assisted reproduction techniques (ART) using cryopreserved semen from patients with cancer.

DESIGN

Prospective.

SETTING

Therapeutic semen banking program at a tertiary healthcare center.

PATIENT(S)

Twenty-nine men with cancer who cryopreserved their sperm before treatment at our facility from 1982 to 2001 and withdrew their samples for assisted reproduction (IUI, IVF, or intracytoplasmic sperm injection [ICSI]).

INTERVENTION(S)

Sperm bank records were used to identify the patients. Information on fertility potential indices was obtained from medical records and through interviews. Of the 29 patients, 9 had testicular cancer, 12 had Hodgkin's disease, and 8 had other types of cancer.

MAIN OUTCOME MEASURE(S)

Pregnancy and live births.

RESULT(S)

A total of 87 ART cycles (42 IUI, 26 IVF, and 19 ICSI) was performed. Of those cycles, 18.3% resulted in pregnancy (7% IUI, 23% IVF, and 37% ICSI), and 75% of the pregnancies resulted in a live birth (100% IUI, 83% IVF, and 57% ICSI). There was no significant difference in the outcomes when the results were stratified by type of ART and malignancy. None of the 11 infants who were born had congenital anomalies.

CONCLUSION(S)

Our findings emphasize the need for physicians to discuss the issue of semen cryopreservation with all men of reproductive age who have cancer before antineoplastic therapy is started.

Oncologists' attitudes and practices regarding banking sperm before cancer treatment

PURPOSE

The goal of this study was to survey oncologists in three different practice settings to determine their knowledge, attitudes, and practices regarding referring patients to bank sperm before cancer treatment.

METHODS

A postal survey about knowledge, attitudes, and practices regarding banking sperm before cancer treatment was sent to 718 oncology staff physicians and fellows at two cancer centers and at sites in a Community Clinical Oncology Program.

RESULTS

The return rate was 24% and did not differ by institution, oncologic specialty, or sex. Fellows were significantly more likely to participate (37%) than staff physicians (20%). Ninety-one percent of respondents agreed that sperm banking should be offered to all men at risk of infertility as a result of cancer treatment, but 48% either never bring up the topic or mention it to less than a quarter of eligible men. Neither greater knowledge about sperm banking nor seeing large numbers of eligible men yearly increased the likelihood of discussing the option. Barriers cited included lack of time for the discussion, perceived high cost, and lack of convenient facilities. Oncologists reported they would be less likely to offer sperm banking to men who were homosexual, HIV-positive, had a poor prognosis, or had aggressive tumors. Oncologists overestimated the costs of sperm banking and the number of samples needed to make cryopreservation worthwhile.

CONCLUSION

Sperm banking should be offered as an option to all men at risk of infertility because of their cancer treatment. Clearer practice standards could help oncologists increase their knowledge about sperm banking and avoid dependence on biased patient selection criteria.

Postmortem sperm procurement

PURPOSE

We determined the prevalence of requests for postmortem sperm procurement and the degree to which procurement is performed by those working in the field of infertility.

MATERIALS AND METHODS

Structured telephone interviews were conducted with personnel at 273 assisted reproductive facilities in the United States and Canada. The number of facilities reporting requests and the number of facilities reporting that they performed the procedure were determined.

RESULTS

The prevalence of requests for postmortem sperm procurement was much greater than initially anticipated. A total of 82 requests was reported at 40 facilities in 22 different states between 1980 and 1995. More than half of the reported requests (43) were made between 1994 and 1995. Of the 82 requests 25 were honored at 14 facilities in 11 different states. No requests or procedures were reported from Canada.

CONCLUSIONS

Medical advances in postmortem sperm procurement, cryopreservation and in vitro fertilization permit retrieval of sperm after death for various purposes, including posthumous fatherhood. There are no explicit ethical guidelines, legislation or relevant case law, and fertility specialists must confront these issues before proceeding in a field fraught with moral and policy uncertainties.

[Use of sperm cryopreservation by tumor patients]

Impairment of spermatogenesis can be expected after cytostatic treatment or radiation for cancer. To improve fertility prognosis, semen samples are usually deep-frozen and stored in liquid nitrogen prior to such a therapy. However, after therapy this deep-frozen sperm is seldom used. Of 47 patients for whom we started cryopreservation of semen during the years 1983-1988, 20 men were no longer interested in further storage within 2 years, so that the deposits were destroyed. Up to now, none of the 27 samples still existing has been used for artificial insemination or in vitro fertilization (IVF). Possible reasons for this are discussed.