Original Research

The clinical outcomes of sperm cryopreservation in chemotherapy patients at a public hospital in the Western Cape

Shannon Govender, Rosaley Prakaschandra

Received: 27 May 2025; Accepted: 19 Mar. 2026; Published: 08 Sept. 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Sperm cryopreservation is the standard method of fertility preservation for men undergoing gonadotoxic cancer treatment. Both malignancy and chemotherapy may impair spermatogenesis and reduce future reproductive potential. Limited evidence exists on sperm cryopreservation outcomes among South African cancer patients.

Aim: To evaluate the clinical outcomes of sperm cryopreservation in cancer patients undergoing fertility preservation.

Setting: An andrology laboratory at a public hospital in the Western Cape, South Africa.

Methods: A retrospective quantitative study reviewed medical records of male cancer patients who underwent sperm cryopreservation between 2002 and 2021. Data collected included referral patterns, cancer diagnoses, pre-treatment semen parameters and the usage and disposal of cryopreserved sperm. Descriptive and inferential statistics were used to compare outcomes across cancer groups. Statistical significance was set at p < 0.05.

Results: A total of 126 patients underwent sperm cryopreservation. The mean age at diagnosis was 26.6 ± 7.0 years. Testicular cancer (27.4%), lymphoma (25.2%) and leukaemia (19.0%) were the most common diagnoses. Significant differences in semen volume were observed across cancer types (p = 0.015). Thyroid cancer and severe aplastic anaemia were associated with the lowest sperm concentration and motility values, although not statistically significant. Only three patients (2.38%) utilised their cryopreserved sperm, while 24 (19.05%) discarded stored specimens (p < 0.001).

Conclusion: Fertility preservation should be routinely discussed with eligible cancer patients before treatment. The low utilisation rate highlights the need for long-term monitoring of fertility preservation outcomes in cancer survivors.

Contribution: This study provides the first South African analysis of sperm cryopreservation outcomes in cancer patients and contributes evidence to inform fertility preservation practice and policy.

Keywords: fertility; malignancy; cancer; assisted reproduction; South Africa; cryopreservation.

Introduction

Fertility treatments like assisted reproductive technology (ART) help infertile couples conceive. These procedures are indicated for couples that face difficulty falling pregnant naturally. These treatments are tailored according to the severity of infertility for both males and females. Assisted reproductive technology is comprised of in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI) and intrauterine insemination (IUI). In addition, oocyte, embryonic and sperm cryopreservation is widely available.¹

Sperm cryopreservation is the standard method of preserving male fertility, especially in patients undergoing chemotherapy. Cancer and radiation therapies greatly impact spermatogenesis, thereby decreasing fertility potential. The effect of chemotherapy greatly impacts the process of sperm production, thus having a direct effect on fertility.² Patients undergoing these treatments receive gonadotoxic treatment, which can severely reduce sperm function and quality, thus lowering the ability to achieve a pregnancy. Therefore, sperm cryopreservation or sperm banking is the preferred method of preserving fertility before the commencement of chemotherapy and radiation therapies to give these individuals an opportunity at fatherhood.²

Even though sperm cryopreservation is the only method for preserving male fertility, there has been a lack of utilisation of this service throughout the years.³ This is because of the under-referrals by oncologists in conjunction with limited practitioner knowledge on fertility preservation. Despite having knowledge about fertility preservation, most practitioners have not put this into practice. This, in turn, contributes to the low rates of fertility preservation services.⁴ In addition, there has been a higher rate of the diagnosis of cancer in younger patients in developing countries. Despite the availability of these services in these developing countries, they have not yet been adequately used. Therefore, adding to the low rates of sperm cryopreservation and, consequently, sperm specimens that are used by cancer patients.⁴

While chemotherapy has its advantages in terms of treatment, it also has detrimental effects on sperm concentration, motility, and morphology. A decline in these sperm parameters is prevalent in these types of patients.⁵ Therefore, the question of which type of malignancy causes worsened semen parameters has been controversial.

In sub-Saharan Africa, there has been an increasing prevalence of cancer. Although cancer treatment is widely available in South Africa, underprivileged communities have limited access to hospitals or knowledge about cancer itself. This is because of a variety of social, political and economic circumstances surrounding low-income households. A local study reported that many people in this population lacked knowledge about the actual causes of cancer and believed it to be incurable and untreatable. Many individuals believed that chemotherapy would aggravate or worsen the cancer conditions.⁶ Despite the availability of sperm cryopreservation globally, little is known about fertility preservation in men diagnosed with cancer in South Africa.

Research methods and design

Study design and population

This retrospective study, positioned within the positivist paradigm, employed a quantitative approach to determine the clinical outcomes of sperm cryopreservation in chemotherapy patients from the Western Cape. The study was conducted at the Andrology laboratory at the Reproductive Medicine Unit at Groote Schuur Hospital in the Western Cape. The participants were primarily male cancer patients who had undergone sperm cryopreservation from 2002 to 2021. The study excluded patients who had already undergone chemotherapy. Patient medical records and files were reviewed to extract data and conduct the research.

Sample size calculation

The sample size for this study was determined using Rao software for sample size calculation (95% confidence interval [CI] & 5% margin of error), based on a review of patient folders and medical records of chemotherapy patients who underwent sperm cryopreservation from 2002 to 2021. A sample size of 126 was deemed sufficient to achieve adequate statistical power for the analysis. The main variables evaluated were the number of patients being referred for fertility preservation, semen parameters according to cancer type and usage and disposal rate.

Data analysis

Data analysis was performed using the Statistical Package for Social Sciences (SPSS) data package (V27). The study employed statistical methods such as descriptive statistics, including frequency counts, percentages, means and standard deviation (s.d.). Other statistical tests included the t-test for comparison of continuous data, while chi-square tests were used for categorical data. Analyses of variance (ANOVA) were used to compare continuous semen data across the different categories of cancer, and post-hoc analysis using Tukey’s was performed to identify specific in-group associations. A p-value of < 0.05 was considered statistically significant. All semen analyses followed the World Health Organization (WHO) Laboratory Manual for the Examination and Processing of Human Semen, 6th edition.⁷

Ethical considerations

Ethics approval was obtained by the Durban University of Technology Institutional Research Ethics Committee (IREC): BIREC 120/22, as well as from the University of Cape Town Human Research Ethics Committee (HREC): HREC REF: 780/22. Permission was obtained to conduct this research within the Department of Obstetrics and Gynaecology prior to commencing the study.

Results

Characteristics of patients

A total of 126 male patients met the inclusion criteria for the study timeframe. Of the 126 patients, three had unknown ages. Therefore, in this respect, there was complete data for 123 participants. The average age and standard deviation (s.d.) were 26.6 ± 7.0 years, respectively. Table 1 presents the data reflecting the age range of these cancer patients. The majority of cancer patients were from the 21–30 age group, representing 52% (n = 65) of the participants. The 31–40-year age group (n = 30, 24%) came next, with 18% (n = 23) of the participants from the 14–20-year age group and the least number from the 40–50-year age group (n = 5.4%).

All the participants provided a fresh ejaculate by masturbation for sperm cryopreservation. Additionally, each participant received a diagnosis of various malignancies (Table 1). The results only included the most common and prevalent types of cancers among the patients. The study excluded other malignancies because of the impossibility of conducting a comparative analysis on cancers that only account for 1% of the population. The majority of the participants were diagnosed with testicular cancer (27.4%), followed by patients with lymphoma (n = 24, 25.2%), leukaemia affected 18 patients (19%). Germ cell tumours accounted for 10.5% of the patients (n = 10), with 6.3% of the patients diagnosed with sarcomas (n = 6). Seminomas affected an additional 5.3% of the participants (n = 5). Both severe aplastic anaemia and thyroid cancer accounted for 3.2% each of the participants (n = 6).

Patients received a variety of treatments after sperm banking, the majority (n = 106, 84.1%) of whom received chemotherapy, followed by 7.9% (n = 10) who received radiation therapy. Six patients had undergone radical orchidectomy (4.76%). Only two patients underwent a bone marrow transplant (2%), and two patients received both chemotherapy and a radical orchidectomy surgery. Table 1 also highlights the average number of straws provided by each patient. A specialised plastic straw is used to store frozen sperm. These straws usually hold 0.5 mL or either 0.25 mL of sperm.⁸ The average number of straws was 13.3 ± 20.18, respectively.

Only 95 patients with the main cancer types were considered for this comparison (N = 95). The diagnoses for these patients included germ cell tumours, leukaemia, lymphoma, sarcoma, seminoma, severe aplastic anaemia and testicular and thyroid cancer. Other malignancies were excluded as they could not be compared, as they made up 1% of the subject population.

The mean age of the subjects was 26 ± 6.71 years. The semen sample volume (measured in mL) in germ cell tumour patients was 2.62 ± 1.58. Leukaemia was 2.75 ± 1.82. Lymphomas accounted for 2.26 ± 1.94. Sarcoma patients represented 1.75 ± 0.82.

Referral for cryopreservation from 2002 to 2021

Only one patient (n = 1) received a referral for sperm cryopreservation in 2002, while 2003 yielded eight patients who stored sperm (Figure 1). There was a drop in sperm banking referrals in 2004, with only one patient undergoing fertility preservation (n = 1). In 2005, 6% of cancer patients underwent fertility preservation (n = 8). However, in 2006, only 2% of cancer patients used this service (n = 3). In 2007, the referral rate for sperm cryopreservation increased to 7% (n = 9). In 2008, only four patients were referred for sperm cryopreservation (3%). Only five patients were referred for fertility preservation in 2009 (4%).

FIGURE 1: Number of patients being referred for sperm cryopreservation from 2002 to 2021.

Figure 1 shows the graphic distribution of patients referred for sperm cryopreservation between 2002 and 2021.

Figure 1 shows that the number of referrals for sperm banking between 2002 and 2021 was extremely variable, with no notable trends. The study found that the greatest number of patients being referred for fertility preservation was in 2015, with 13 patients being referred and storing specimens at the laboratory.

Semen parameters according to cancer type

The mean semen sample volume in seminoma patients was 4.6 ± 1.14. Severe aplastic anaemia was 1.83 ± 0.28. The mean semen sample volume in testicular cancer patients was 2.99 ± 1.74. Lastly, the mean semen sample volume in thyroid cancer patients was 2.67 ± 0.29. Analyses of variance showed p = 0.015, which denoted a statistically significant difference across all groups of cancers for semen volume. Post-hoc analysis identified specific statistical significance between lymphoma and seminoma (p = 0.007).

Table 2 highlights that the sperm concentration in patients with germ cell tumours was 29.2 ± 25.48. Leukaemia was 44.5 ± 40.35. Lymphomas represented 60.95 ± 37.63. The mean sperm concentration in sarcoma patients was 82 ± 18.76. Seminoma patients were 53.4 ± 39.91. The average sperm concentration in severe aplastic anaemia was 16.33 ± 13.05. Testicular cancer accounted for 30.81 ± 21.78. Lastly, the mean sperm concentration in thyroid cancer patients was 14 ± 18.24. However, these associations were not statistically significant (p = 0.38).

Sperm motility in germ cell tumours was 44.5 ± 21.27. Leukaemia patients had a mean sperm motility of 40.27 ± 18.58. Lymphomas represented 53.33 ± 12.91. Sarcoma patients had a mean sperm motility of 47.5 ± 14.05. The mean sperm motility in seminoma patients was 42 ± 21.97. Patients diagnosed with severe aplastic anaemia had a mean sperm motility of 20 ± 10. Testicular cancer patients had an average sperm motility of 50.4 ± 9.78. In addition, thyroid cancer patients had an average sperm motility of 35 ± 22.91. Similarly, these associations were not statistically significant (p = 0.099).

Usage and disposal rates of cryopreserved sperm

Of the 126 patients, only 3 (2.38%) used the sperm that was cryopreserved at the facility (Table 3). There were 24 patients (19.05%) who discarded sperm specimens, with one patient (4.16%) out of the 24 patients who discarded sperm allowing the laboratory to discard the frozen specimen because of the return of fertility. Twelve patients (50%) had specimens discarded as a result of death.

The remaining 11 patients (45.83%) in the discard group gave permission to the laboratory to discard the specimen because of a lack of finances to continue storing the sperm or no interest in utilising it in the future. The study results revealed that the facility currently stored 102 samples. The results indicate that there was a statistically significant relationship between the usage and disposal rates of cryopreserved sperm (p < 0.001).

Discussion

Patient age at diagnosis

Out of the 126 patients who made up the study population, 52% of patients were in the age group range of 21-30 years. The age trends are shown in Table 1. The study findings were not in keeping with international trends as a study undertaken in Beijing found that the highest number of cancer cases requiring fertility preservation was in the 30–39-year age group.⁹ However, the study highlighted that there were low numbers of patients in the 40-year-old age group and onwards, which is similar to our study findings. The disparity in age with regard to cancer prevalence is because of the notion of reproductive age. Previous studies highlighted that the majority of patients undergoing fertility preservation were aged between 15 years and 39 years.⁹ This indicates that there is a much greater need for sperm banking procedures in younger men during reproductive age. Our results are in keeping with a study conducted by Abdel-Razeq et al., who highlighted the higher percentage of patients who developed cancer at a young age.¹⁰

The study additionally reported that older patients, particularly in the 40-year age group and onwards, primarily desired to preserve fertility even though the partners of these patients had already given birth. Also, Abdel-Razeq et al.’s¹⁰ study showed that male patients between the ages of 14 years and 40 years who did not have any children were more likely to have cryopreserved sperm during these reproductive years.

Type of cancer

The most common types of cancer in the present study were testicular cancer, lymphoma, leukaemia, germ cell tumours, sarcomas, seminomas, severe aplastic anaemia and thyroid cancer. The present study found that more patients were diagnosed with testicular cancer, with 27% of patients being diagnosed with testicular cancer in comparison to the other types of malignancies. These findings are in keeping with international trends. A 10-year retrospective study undertaken in Switzerland discovered that the predominant cancer was also testicular cancer. This was followed by lymphomas and leukaemia.¹¹ Similarly, this is in keeping with the present study findings, as lymphomas and leukaemia both followed testicular cancer.

Testicular cancer is one of the most common types of malignancies in patients aged 15–45 years. A study by Gaddam and Chestnut reported that the incidence of testicular cancer has doubled in the last 40 years.¹² Factors comprising both genetic and environmental enterprises can lead to the development of testicular cancer. These include family histories, infections, cryptorchidism and testicular trauma. These risk factors molecularly give rise to testicular cancer, thus resulting in the prevalence of testicular cancer. Environmental endocrine disruptors (EDC’s) such as the use of pesticides and solvents are regarded as the ‘by – products of industrialisation and urbanisation’. This could elucidate the high occurrence of testicular cancer in young adults in more industrialised countries. However, evidence of EDC’s and its exact contribution to testicular cancer in young adult men is limited and scarce.¹³

Patient referral for sperm cryopreservation from 2002 to 2021

The present study found that over a 19-year period, the number of patients referred for sperm cryopreservation varied annually. The study found that the highest number of patients being referred for fertility preservation in a single year was in 2015, with 13 patients being referred for sperm banking. A similar study was conducted in Beijing, which reported an increase in the number of patients undergoing sperm cryopreservation from 2015 to 2019.⁹ Another study conducted in the United States (US) found that there was an increase in the number of sperm cryopreservation cases from 2008 to 2017.¹⁴ The present study findings revealed a decrease in fertility preservation cases from 2015 to 2019. The present study’s findings were also not in keeping with international trends in terms of the number of patients being referred for sperm cryopreservation over that particular duration. This is because international studies involved a larger cohort of participants.⁹ However, the present study found that there was a decrease in sperm cryopreservation services in 2020. This finding aligns with the findings of the Beijing study, which also reported a decrease in sperm cryopreservation services in 2020,⁹ probably as a result of the COVID-19 pandemic. This was prevalent in both of the studies.

It is also important to note that there had been an increase in sperm cryopreservation cases from 2008 because of the fact that fertility preservation services had and still have a growing interest and need to preserve male fertility in cancer patients.⁹ The current study’s findings support this claim, as there was a documented rise in sperm cryopreservation cases since 2011. This is likely because of the growing interest in and popularity of studies that show how important it is to preserve male fertility in patients who are receiving gonadotoxic therapies.

Semen parameters according to the type of cancer

The question as to which type of malignancy resulted in worsened semen parameters remains controversial.¹⁵ The findings of this present study, relating to which type of malignancy causes worsened semen parameters, were achieved by highlighting the mean values of semen sample volume, sperm concentration and motility in each of the cancers presented. The results of this study found that the mean sperm concentration was lower in patients diagnosed with thyroid cancer (14 ± 18.24) as well as severe aplastic anaemia (16.33 ± 13.05), albeit not reaching statistical significance. The question of why this resulted in lower sperm concentration and motility is unknown. However, the amount of chemotherapy and radiation doses administered to these patients prior to their fertility preservation could potentially be the cause if any such treatment was initially administered.¹⁶ More than that, this study showed that sperm motility was lower in people with severe aplastic anaemia (20 ± 10) and thyroid cancer (35 ± 22.91). Notably, there were significant differences found in mean semen sample volume across all the types of malignancies with regards to normal values of semen volumes, particularly between patients with seminomas and lymphomas (p = 0.015). This finding aligns with the current literature, which suggests that systemic cancers like lymphoma impact semen volume more profoundly as a result of systemic inflammation, cytokine release and disruption of the hypothalamic-pituitary-gonadal axis, than other typically localised cancers like seminomas, which are less disruptive to hormonal and reproductive function.¹⁷

This is at variance with international trends, as a similar retrospective study conducted in the US found that testicular cancer resulted in decreased sperm concentration as well as total motile sperm count. The present study found that testicular cancer had worsened sperm concentration results compared to the following malignancies: Leukaemia, seminomas, lymphomas and sarcomas. However, testicular cancer had a higher sperm motility result compared to the other seven malignancies besides lymphomas. Although the authors could not explain the aetiology for impaired semen quality, it is hypothesised that testicular dysgenesis in patients diagnosed with testicular cancer is a proposed mechanism for extreme deterioration.¹⁵ Similarly, another study conducted in 2021 also found that patients diagnosed with testicular cancer had significantly lower sperm concentration.¹⁸

In contrast, a study conducted in China found that patients diagnosed with sarcomas had a significant reduction in total sperm motility count, followed by testicular cancer and leukaemia.¹⁹ However, the results of the present study found that patients diagnosed with sarcoma had a significantly higher mean sperm concentration as well as mean sperm motility. In an interesting twist, this study found that people with germ cell tumours or testicular cancer had lower mean sperm concentrations (29.2 ± 25.48) for germ cell tumours and testicular cancer (30.81 ± 21.78) than people with leukaemia and lymphomas. However, patients diagnosed with leukaemia had lower sperm motility when compared to germ cell tumours, lymphoma and testicular cancer.

In keeping with earlier studies conducted in the US, our study showed no statistically significant difference in total sperm count or motility when comparing patients diagnosed with testicular cancer, lymphomas, leukaemia and other types of cancers.²⁰

Usage and disposal rates of cryopreserved sperm

The usage and disposal rate of these specimens plays an integral role in understanding whether these groups of patients have actually returned to ART clinics to conceive. In the present study, the usage and disposal rate were determined by determining how many patients used specimens that were cryopreserved, how many specimens were discarded and how many specimens were still stored at the Andrology laboratory. The results of the present study found that only 2.4% of patients used the samples that were stored. Additionally, the study found that there were 19.18% of patients who disposed of their samples.

A similar study conducted in Japan found that the usage rate of cryopreserved sperm was relatively low (8%) in comparison to the disposal rate (16%).²¹ Similarly, another study conducted in China found that the usage rate of cryopreserved sperm was also low (< 10%).¹⁹ This is in keeping with many international studies that have reported the same outcome. However, it is reported that in China, the cost of fertility preservation, regarding sperm cryopreservation, is not covered by national insurance, which serves as a limitation. In contrast, the Andrology laboratory of the present study does not charge cancer patients for sperm cryopreservation services. Therefore, the low number of patients utilising or even referring for fertility preservation in this present study was not because of cost.

The present study findings found that the samples that were disposed of were because of return of fertility, death and lack of finances to continue storing the specimen at the facility. This is in keeping with international trends. Kawai and Nishiyama’s study revealed that the gap between the usage rate and the disposal of more samples was because of patients’ simple ‘abandonment’ of samples or the return of fertility and spermatogenesis as the main causes.²¹ This aligns with the current study’s findings, which indicate that a significant number of samples remain stored at the andrology facility.

Strengths

This study represents the first comprehensive investigation into cancer patients who have undergone sperm cryopreservation and its subsequent outcomes in South Africa. The findings provide valuable insights from a South African perspective on cancer patients and their outcomes, thereby contributing to and enhancing the current body of international knowledge and evidence.

Limitations

The sample population of 126 patients is relatively small for a study spanning 19 years. Additionally, the number of patients diagnosed with severe aplastic anaemia and thyroid cancer was limited to just three individuals each.

Conclusion

The present study found that the number of patients undergoing sperm cryopreservation varied in each year from 2002 to 2021. However, as fertility preservation services gained popularity, there was an increase in certain years of the study. The study revealed that semen parameters related to sperm concentration and motility deteriorated as a result of thyroid cancer and severe aplastic anaemia. Testicular cancer was found to have worsened sperm concentration compared to other types of cancer, besides severe aplastic anaemia and thyroid cancer, but greater sperm motility results compared to all the other malignancies, besides lymphomas. In addition, the study found that there was a low usage rate and a higher disposal rate, with many samples still stored at the andrology facility.

This research has provided a South African perspective of sperm cryopreservation in cancer patients. It emphasises the need for fertility preservation in these patients and the need to report usage, disposal and pregnancies from sample use. This should also serve as a recommendation to oncologists and medical personnel to refer patients for fertility preservation as soon as a diagnosis is made and to report the outcomes of that particular patient.

Acknowledgements

This article is based on research originally conducted as part of Shannon Govender’s Honour’s degree titled ‘The clinical outcomes of sperm cryopreservation in chemotherapy patients at a public hospital in the Western Cape’, submitted to the Durban University of Technology, 2023. The thesis is currently unpublished and not publicly available. The thesis was supervised by Rosaley Prakaschandra. The thesis was reworked, revised and adapted into a journal article for publication. The author confirms that the content has not been previously published or disseminated and complies with ethical standards for original publication.

The authors would like to thank the Department of Obstetrics and Gynaecology and the Reproductive Medicine Unit: Andrology of Groote Schuur Hospital for the support given to this research.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Shannon Govender: Conceptualisation, Investigation, Methodology, Project administration, Writing – original draft. Rosaley Prakaschandra: Formal analysis, Supervision, Validation, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data sharing is not applicable to this article as no new data were created or analysed in this study.

The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

References