Fertility preservation for men with testicular cancer: Is sperm cryopreservation cost effective in the era of assisted reproductive technology?

Many patients do not cryopreserve sperm before undergoing cancer treatment because of high perceived costs of cryopreservation. We sought to investigate the cost-effectiveness of fertility preservation compared to posttherapeutic fertility treatment in testicular cancer patients.We performed a systematic search of the PubMed database for the following: risk of azoospermia 12 months after surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy (RT); rates of natural conception, and rates of conception with the use of intrauterine insemination or assisted reproductive technology, with or without microsurgical testicular sperm extraction (microTESE). A decision tree was constructed using the TreePlan add-in for Microsoft Excel (TreePlan Software, San Francisco, California). Cost-effectiveness was calculated as the overall cost of a given management branch, divided by likelihood of pregnancy. Calculations accounted for variable number of years of cryopreservation, and variable costs of microTESE.1,113 articles were identified; 44 were included in the final analysis. Overall probability of pregnancy was higher among couples who cryopreserved sperm, versus those who did not. In patients undergoing active surveillance or retroperitoneal lymph node dissection, cryopreservation was more cost-effective if storage time was short (<6 years) or microTESE cost was high (>7,000). Cryopreservation prior to chemotherapy was more cost-effective unless microTESE cost was low (<7,000). Cryopreservation prior to RT was more cost-effective in almost all scenarios.Sperm cryopreservation prior to undergoing chemotherapy or RT remains the most cost-effective strategy for fertility preservation, across a range of possible costs associated with surgical sperm retrieval and in vitro fertilization/intracytoplasmic sperm injection.