Evidence-based recommendation for male fertility problems and sexual dysfunction (IGHG a) b, c

This page is part of the PanCare follow-up recommendations for surveillance of late effects. Click here, for more information on these recommendations.

Who is at risk for male fertility problems and sexual dysfunction?

Male CAYA cancer survivors

  • treated with alkylating agents
  • treated with radiotherapy to a volume exposing the testes, including TBI
  • treated with surgery to the spinal cord, sympathetic nerves or pelvis
  • who are hypogonadal

What problems might occur?

  • Impaired fertility
  • Impaired spermatogenesis (after alkylating agents or radiotherapy to a volume exposing the testes)
  • Testosterone deficiency (after radiotherapy potentially exposing the testes ≥ 12 Gy or TBI)
  • Physical sexual dysfunction (after surgery to the spinal cord, sympathetic nerves or pelvis, or radiotherapy to volumes exposing the testes or pelvis, or who are hypogonadal)

What surveillance modality should be used and at what frequency should it be performed?

All survivors at risk:

  • Counselling regarding the risk of impaired spermatogenesis, testosterone deficiency and physical sexual dysfunction (including erectile and ejaculatory dysfunction), and its implications for future health and fertility at the request of the survivor after informed discussion or when paternity is desired in the foreseeable future at least every 5 years

For pre- and peri-pubertal survivors at risk d:

  • Monitoring of growth (height) and pubertal development and progression (Tanner stage including testicular volume) e after radiotherapy ≥12 Gy to volumes exposing the testes or TBI, at least every year, with increasing frequency as clinically indicated depending on growth and pubertal progress

For post-pubertal survivors at risk:

  • Semen analysis for survivors who desire assessment about possible future fertility
  • Measurement of testosterone in an early morning blood sample at clinically appropriate intervals after radiotherapy ≥ 12 Gy to volumes exposing the testes or TBI; measurement of LH in the presence of clinical signs of hypogonadism, or of previous low-normal or borderline testosterone concentrations, or if it is not possible to obtain an early morning blood sample, in addition to testosterone, at least every 2-3 years
  • A sexual history for survivors treated with surgery to the spinal cord, sympathetic nerves, or pelvis, or radiotherapy potentially exposing testes or pelvis, or those who are hypogonadal, every 5 years

What should be done if abnormalities are identified?

Refer to male reproductive medicine, andrology, endocrinology or urology those survivors with severely impaired spermatogenesis e, those who are seeking paternity, those whose attempts to conceive have been unsuccessful for ≥6 months, regardless of sperm count, those whom laboratory results suggest testosterone deficiency, or who have symptoms suggesting physical sexual dysfunction


While PanCare strives to provide accurate and complete information that is up-to-date as of the date of publication, we acknowledge that the sequence of referral and diagnostic tests might vary according to the local and national healthcare system logistics.

It is recognised that survivors and their healthcare professionals have the final responsibility for making decisions concerning their long-term follow-up care. As such, they may choose to either adopt these recommendations or not to do so after individual informed discussion. It is good practice to document this decision.

In addition to regular surveillance, real-time awareness and prompt reporting of new symptoms and signs is essential to the early detection and timely treatment of late effects.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information.

The PanCare materials are free to use for anyone aiming to inform about late effects and long-term survivorship care. However, no financial advantage may be achieved. All communication should reference PanCare and link to the PanCare website.

a This recommendation reflects the content of the IGHG Male Gonadotoxicity guideline (Recommendations for gonadotoxicity surveillance in male childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group in collaboration with the PanCareSurFup Consortium, Lancet Oncology, 2017; accessible through

b Further recommendations regarding height are specified in the Consensus-based recommendation for health promotion.

c Further recommendations regarding central hypogonadism are specified in the Evidence-based recommendation for hypothalamic-hypopituitary disorders.

d Regular growth and pubertal monitoring should be started by no later than 12 years (and no earlier than 10 years) of age. The pubertal increase in growth velocity may be impaired if growth hormone deficiency is also present in survivors who received cranial radiation

e Severe oligospermia (sperm counts ≤ 5×106/ml)