Prostate cancer and fertility: Preserving hope for fatherhood after diagnosis

DEAR Dr G,

I am in my mid-50s and lost my wife during the first wave of Covid five years ago. I only began dating again in recent years, and am now happily attached to a partner who is considerably younger than me. We are very compatible in both our lifestyle and sexual desires.

The only issue is that my partner has never had a child, and we are both eager to start a family. Sadly, I am devastated after being diagnosed with prostate cancer last month. I have always known I was at risk, as my brother also had this malignancy at a young age. I also understand that prostate cancer is associated with breast cancer, which runs in my family.

My urologist is keen to begin treatment for my cancer. However, I am reluctant to start treatment immediately, as I understand the prostate is crucial for reproductive health and treatment could make me infertile. I have researched all the treatment options and want to choose one that is least destructive.

I hope to put Dr G on the spot for some guidance with minimal reproductive impairment.

Can you tell me what impact prostate cancer has on male fertility? In addition, will treatment for prostate cancer render me infertile? Lastly, what options do I have to eradicate the cancer while preserving my fertility?

I look forward to your response.

Regards,

Fertile Fergus (soon no more)

Prostate cancer is one of the most common malignancies affecting men, especially those over 50. Advances in screening, diagnosis, and treatment have significantly improved survival. However, prostate cancer and its management can profoundly impact male reproductive health. While many men diagnosed with prostate cancer are beyond their reproductive years, increasing numbers of younger men are affected, raising important concerns about fertility preservation.

The prostate gland does not produce sperm, but it does contribute seminal fluid that nourishes and protects sperm during ejaculation. Cancer confined to the prostate generally does not directly impair sperm production. However, advanced cancer may spread to nearby structures or require systemic treatments that can compromise sperm quality. Psychological and hormonal changes also play a role in fertility for men with prostate cancer. The stress of a cancer diagnosis can lower testosterone and libido, indirectly reducing fertility potential. In rare cases, tumours may disrupt the hypothalamic–pituitary–gonadal axis, impairing sperm production.

Treatment for prostate cancer affects fertility more than the disease itself. Radical prostatectomy, or complete removal of the prostate and seminal vesicles, means men will no longer produce semen, making natural conception impossible. Erections can sometimes be preserved with nerve-sparing surgery, but ejaculation is lost, as the pathway for semen is removed. Many men wishing to preserve fertility choose sperm freezing and assisted reproduction.

External beam radiation or brachytherapy can damage surrounding tissues, including the testes, and cause DNA damage to sperm, which reduces fertility. Ejaculate volume may decrease, and erectile dysfunction can develop over time after radiotherapy. Some genetic damage may be passed to offspring if conception occurs soon after radiation; fertility specialists usually recommend waiting 6–12 months before starting fertility treatments.

Hormone therapy, also known as androgen deprivation therapy (ADT), will definitely impact fertility in prostate cancer. The medication lowers testosterone to slow cancer growth, but this suppresses sperm production, leading to infertility. It also reduces libido and erectile function. Occasionally, fertility may return after stopping radiotherapy, but long-term hormone therapy often causes irreversible impairment of sperm production.

Chemotherapy, used mainly in advanced or metastatic prostate cancer, has a direct toxic effect on testicular germ cells. This can cause permanent azoospermia, or absence of sperm production. Fertility recovery depends on age, drug type, and duration, but is often incomplete.

Men diagnosed with prostate cancer who wish to father children should consider fertility preservation before treatment begins. Sperm banking (cryopreservation) is the most reliable method, recommended before surgery, chemotherapy, or radiation. Testicular sperm extraction (TESE) can be performed if ejaculation is not possible but sperm production is intact. Assisted reproductive technologies (ART), including in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), allow conception using preserved sperm.

Counselling by fertility specialists is vital in educating patients about risks and preservation strategies. Psychosocial considerations are important, as loss of fertility can affect self-image and sexual relationships. Couples may experience stress when fertility is threatened, and early counselling can help. Ethical concerns, such as the safety of conception after radiation or chemotherapy, should also be discussed.

The famous actor Hugh Jackman once said, "Until you go through infertility, you don’t realise how devastating it can be." Prostate cancer itself is tough, but its treatments—particularly radical prostatectomy, radiation therapy, hormone therapy, and chemotherapy—also pose significant risks to male fertility. As more younger men face this diagnosis, fertility preservation strategies such as sperm banking are essential considerations before starting therapy. A multidisciplinary approach involving oncologists, urologists, and fertility specialists ensures that men are informed of their options and supported in preserving their reproductive potential. Dr G is often put on the spot to counsel men facing the difficult choice between cancer treatment and preserving fertility.