Testicular tissue cryopreservation is an experimental method to preserve the fertility of prepubertal patients before they initiate gonadotoxic therapies for cancer or other conditions. Here we provide the proof of principle that cryopreserved prepubertal testicular tissues can be autologously grafted under the back skin or scrotal skin of castrated pubertal Rhesus macaques and matured to produce functional sperm. During the eight-to twelve-month observation period, grafts grew and produced testosterone. Complete spermatogenesis was confirmed in all grafts at the time of recovery. Graft-derived sperm were competent to fertilize Rhesus oocytes, leading to preimplantation embryo development, pregnancy, and the birth of a healthy female baby. Pending the demonstration that similar results are obtained in non-castrated recipients, testicular tissue grafting may be applied in the clinic.

SUMMARY Hormone suppression given before or after cytotoxic treatment stimulates recovery of spermatogenesis from endogenous and transplanted spermatogonial stem cells (SSC) and restores fertility in rodents. To test whether the combination of hormone suppression and transplantation could enhance the recovery of spermatogenesis in primates, we irradiated (7 Gy) the testes of 12 adult cynomolgus monkeys and treated 6 of them with GnRH-antagonist (GnRH-ant) for 8 weeks. At the end of this treatment, we transfected cryopreserved testicular cells with GFP-lentivirus and autologously transplanted them back into one of the testes. The only significant effect of GnRH-ant treatment on endogenous spermatogenesis was an increase in the percentage of tubules containing differentiated germ cells (tubule differentiation index; TDI) in the sham-transplanted testes of GnRH-ant-treated monkeys compared to radiation-only monkeys at 24 weeks after irradiation. Although transplantation alone after irradiation did not significantly increase the TDI, detection of lentiviral DNA in the sperm of one radiation-only monkey indicated that some transplanted cells colonized the testis. However, the combination of transplantation and GnRH-ant clearly stimulated spermatogenic recovery as evidenced by several observations in the GnRH-ant-treated monkeys receiving transplantation: (a) significant increases (~20%) in the volume and weight of the testes compared to the contralateral sham-transplanted testes and/or to the transplanted testes of the radiation-only monkeys; (b) increases in TDI compared to the transplanted testes of radiation-only monkeys at 24 weeks (9.6% vs. 2.9%; P=0.05) and 44 weeks (16.5% vs. 6.1%, P=0.055); (c) detection of lentiviral sequences in the sperm or testes of five of the GnRH-ant–treated monkeys; and (d) significantly higher sperm counts than in the radiation-only monkeys. Thus hormone suppression enhances spermatogenic recovery from transplanted SSC in primates and may be a useful tool in conjunction with spermatogonial transplantation to restore fertility in men after cancer treatment.

It is important to develop methods to prevent or reverse the sterility caused by chemotherapy or radiation therapy for cancer in men. Using a rat model, we have shown that infertility after testicular exposure to moderate doses of radiation and some chemotherapeutic agents occurs as a result of the inability of spermatogonia to differentiate. There is evidence that this phenomenon also occurs in men. Spermatogenesis and fertility can be restored in rats following treatment with radiation or some chemotherapeutic agents by suppressing testosterone with gonadotropin releasing hormone (GnRH) agonists or antagonists either before or after the cytotoxic insult. However, species differences exist in the testicular response to radiation or GnRH antagonist therapy, so rescue protocols that work in rodents do not work in nonhuman primates. The applicability of this procedure to humans is still largely unknown. In rodents, suppression of testosterone with GnRH analog treatment also appears to enhance the success of spermatogonial transplantation-an option when all stem cells are killed by cytotoxic therapy.

Improved therapies for cancer and other conditions have resulted in a growing population of long-term survivors. Infertility is an unfortunate side effect of some cancer therapies that impacts the quality of life of survivors who are in their reproductive or pre-reproductive years. Some of these patients have the opportunity to preserve their fertility using standard technologies that include sperm, egg or embryo banking, followed by in vitro fertilization and/or embryo transfer. However, these options are not available to all patients, especially the prepubertal patients who are not yet producing mature gametes. For these patients, there are several stem cell technologies in the research pipeline that may give rise to new fertility options and allow infertile patients to have their own biological children. We will review the role of stem cells in normal spermatogenesis as well as experimental stem cell based techniques that may have potential to generate or regenerate spermatogenesis and sperm. We will present these technologies in the context of the fertility preservation paradigm, but we anticipate that they will have broad implications for the assisted reproduction field.

Irradiation of LBNF1 rat testes induces arrest of spermatogonial differentiation, which can be reversed by suppression of testosterone with GnRH antagonist treatment. The cause of the arrest is unknown. We investigated the time course and hormonal effects on radiation-induced arrest and changes in interstitial fluid volume. We postulated that the edema evident in irradiated testes caused the differentiation blockade. Rat testes were irradiated with 3.5 or 6 Gy. Interstitial fluid testosterone (IFT) increased between 2 and 6 wk after irradiation, followed by increased interstitial fluid volume at 6 wk and spermatogonial blockade at 8 wk. Additional rats irradiated with 6 Gy were given GnRH antagonist, alone or with exogenous testosterone, for 8 wk starting at 15 wk after irradiation. In rats treated with GnRH antagonist, IFT started falling within 1 wk of treatment, followed by interstitial fluid volume decreases at wk 2 and 3, with recovery of spermatogenesis starting at wk 4. Addition of exogenous testosterone largely blocked the effects of GnRH antagonist on IFT, interstitial fluid volume, and spermatogenesis. Thus the testicular edema was largely modulated by intratesticular testosterone levels. The time course of changes in the spermatogonial blockade more closely followed that of the testicular edema than of IFT, indicating that testosterone may block spermatogonial differentiation indirectly by producing edema. This conclusion was further supported by an experiment in which irradiated rats were treated with GnRH antagonist plus estrogen; the treatment further reduced IFT and interstitial fluid volume and reduced the time to initiation of recovery of spermatogonial differentiation. These results suggest that studies of the edematous process or composition of the fluid would help elucidate the mechanism of spermatogonial arrest in toxicant-treated rats.