Does distance deter male fertility preservation?

For patients with cancer under-going gonadotoxic therapies who wish to undergo sperm banking, distance may have an impact on their decision for making the trek from their homes to the clinic according to a new retrospective study. Overall, researchers at the University of Pittsburgh Medical Center (UPMC) found that distance seemed to play a role in whether or not men underwent fertility preservation (FP).

The study appears in JCO Oncology Practice (doi:10.1200/OP.22.00789).

The study authors note that although nearly 90% of the US population lives within a half-hour’s drive to a urologist, there is a steep dropoff for males who live close to specialists and medical centers offering FP. Lead author Daniel Pelzman, MD, resident physician at UPMC’s Department of Urology in Pittsburgh, Pennsylvania, says that this was a key reason prompting the study. “There has been so little research done about geography as a potential barrier to fertility preservation in men. We believe this is the first study to investigate whether the distances from fertility centers decreased the odds of males taking advantage of FP after referral.”

For the study, the researchers investigated male patients who were referred to the UPMC fertility clinic for FP between 2013 and 2021. Each subject had at least reached puberty, and all had FP recommended by a reproductive specialist. Semen was collected at a time chosen by the patients. Although not all patients saw a reproductive urologist before FP, all of them agreed to counseling with an FP coordinator by phone or in person.

Specifically, the study reported that for all cancer types, 73.6% (182) of the patients who lived no more than 20 miles away from the UPMC fertility clinic underwent FP. Although a slightly higher proportion of those living 20–40 miles away (70 men) underwent FP (76.1%), rates consistently dropped the farther out people lived from the UPMC fertility clinic; only 59.6% (28 of 47) of the patients who lived 40–60 miles from the clinic and 58.3% (14 of 24) of the patients who lived 80–100 miles from the clinic underwent sperm banking at the UPMC fertility clinic. Still, the researchers noted that the proportion of patients undergoing FP was consistently high (i.e., >50%). “This finding confirms that men want to pursue fertility preservation after referral, even if it is difficult logistically,” Dr Pelzman concluded.

Timothy D. Gilligan, MD, vice-chair for education and associate professor of medicine at the Cleveland Clinic’s Taussig Cancer Institute in Cleveland, Ohio, agrees that men would be more likely to complete sperm banking if there were a facility for doing so closer to where they live. “The study was not able to determine whether the men who lived farther away simply went somewhere else closer to do sperm banking, however,” he adds. “In other words, it’s possible that the men who did not complete sperm banking in Pittsburgh did complete it somewhere else.”

Dr Gilligan says that a more robust study design would have entailed contacting the subjects of the study to determine whether they had completed sperm banking at a different facility. He adds that one limitation of the study is the denominator: The researchers looked at men who were referred, but it is not known how many men should have been referred but were not.

The ultimate question is what percent of men who are appropriate candidates for sperm banking and who want to have their fertility preserved end up being referred for sperm banking and then complete sperm banking,” says Dr Gilligan. “There can be failures to offer fertility preservation, to make fertility preservation feasible, and by the patient to follow through with sperm banking even if it is feasible. If our goal is for men who desire to preserve their fertility to be able to do so, then we need to look at all of the different points in the process where things may break down.”

Dr Gilligan also laments that access to care in the United States varies by region. “Rural areas are famously underserved,” he says. “There is not only the cost of running such a clinic but also the problem of liability in case the specimen is mishandled or not properly stored.” If sperm banking were offered more widely, he believes more men would preserve their sperm.

One solution proposed by the study authors is mail-in semen cryopreservation services. Although the authors believe that this could emerge as a viable option, at this time there are minimal data on how reliable or accurate this option is.

Dr Gilligan agrees. “As the study mentions, mail-in semen cryopreservation kits may be a much more economically feasible solution than trying to set up a fertility preservation clinic in every town.”

A key takeaway for Dr Gilligan is that clinicians must not only remember to offer cryopreservation to appropriate patients and to make referrals for those who want to do so but also need to talk with them about barriers to completing FP, including economic, cultural, logistical, and emotional issues. “A diagnosis of cancer is often terrifying and disorienting, and patients are often so worried about surviving their cancer that fertility does not seem like a priority, even if it will be a priority in the future,” he says. “One thing we can do is to validate the importance that many people put on fertility and to help them recognize that even if they aren’t worried about fertility in the aftermath of their cancer diagnosis, they may well feel differently in the future when their treatment has been completed.

“Fertility preservation is about preserving your future options so that you aren’t taking options away from your future self,” he continues. “In this complicated context, living a long distance from the fertility preservation clinic can become yet another barrier, and clinicians can help patients by strategizing with them about ways to overcome such logistical challenges.”

Dr Pelzman believes that the takeaway messages from the study are twofold. “First, hospital systems and providers should increase their efforts to ensure access to fertility preservation even for men living far from fertility centers. More importantly, however, distance should not preclude referral to a reproductive specialist, as a high percentage of men from all distances will pursue fertility preservation if referred.”