Page 141 - Remedial Andrology

increased risk of developing testicular cancer and should perform regular testicular self-examination [1641].
There is also observational study data suggesting that cryptorchidism may be a risk factor for worsening
clinical stage of seminoma but this needs to be substantiated with future prospective studies [1642].

10.4.1.2 Disease management
10.4.1.2.1 Hormonal treatment
Human chorionic gonadotropin or GnRH is not recommended for the treatment of cryptorchidism in adulthood.
Although some studies have recommended the use of hormonal stimulation as an adjunct to orchidopexy
to improve fertility preservation, there is a lack of long-term data and concerns regarding impairment to
spermatogenesis with the use of these drugs [1643].

10.4.1.2.2 Surgical treatment
In adolescence, removal of an intra-abdominal testis (with a normal contralateral testis) can be recommended,
because of the risk of malignancy [1644]. In adults, with a palpable undescended testis and a normal functioning
contralateral testis (i.e., biochemically eugonadal), an orchidectomy may be offered as there is evidence that the
undescended testis confers a higher risk of GCNIS and future development of GCT [1645] and regular testicular
self-examination is not an option in these patients. In patients with unilateral undescended testis (UDT) and
impaired testicular function on the contralateral testis as demonstrated by biochemical hypogonadism and/
or impaired sperm production (infertility), an orchidopexy may be offered to preserve androgen production and
fertility. However, multiple biopsies of the UDT are recommended at the time of orchidopexy to exclude intra-
testicular GCNIS as a prognostic indicator of future development of GCT (Panel consensus opinion). As indicated
above, the correction of bilateral cryptorchidism, even in adulthood, can lead to sperm production in previously
azoospermic men and therefore may be considered in these patients or in patients who place a high value on
fertility preservation [1646]. Vascular damage is the most severe complication of orchidopexy and can cause
testicular atrophy in 1-2% of cases. In men with non-palpable testes, the post-operative atrophy rate was 12% in
cases with long vascular pedicles that enabled scrotal positioning. Post-operative atrophy in staged orchidopexy
has been reported in up to 40% of patients [1647]. At the time of orchidectomy in the treatment of GCT, biopsy of
the contralateral testis should be offered to patients at high risk for GCNIS (i.e., history of cryptorchidism, < 12 mL
testicular volume, poor spermatogenesis [1648]).

10.4.1.3 Summary of evidence recommendations for cryptorchidism

Summary of evidence LE
Cryptorchidism is multifactorial in origin and can be caused by genetic factors and endocrine 2a
disruption early in pregnancy.
Cryptorchidism is often associated with testicular dysgenesis and is a risk factor for infertility and 2b
GCTs and patients should be counselled appropriately.
Paternity in men with unilateral cryptorchidism is almost equal to men without cryptorchidism. 1B
Bilateral cryptorchidism significantly reduces the likelihood of paternity and patients should be 1B
counselled appropriately.

Recommendations Strength rating
Do not use hormonal treatment for cryptorchidism in post-pubertal men. Strong
If undescended testes are corrected in adulthood, perform simultaneous testicular biopsy, Strong
for the detection of intratubular germ cell neoplasia in situ (formerly carcinoma in situ).
Men with unilateral undescended testis and normal hormonal function/spermatogenesis Strong
should be offered orchidectomy.
Men with unilateral or bilateral undescended testis with biochemical hypogonadism and or Weak
spermatogenic failure (i.e., infertility) may be offered unilateral or bilateral orchidopexy, if
technically feasible.

10.4.2 Germ cell malignancy and male infertility
Testicular germ cell tumour (TGCT) is the most common malignancy in Caucasian men aged 15-40 years, and
affects approximately 1% of sub-fertile men [1649]. The lifetime risk of TGCT varies among ethnic groups and
countries. The highest annual incidence of TGCT occurs in Caucasians, and varies from 10/100,000 (e.g., in
Denmark and Norway) to 2/100,000 (e.g., in Finland and the Baltic countries). Generally, seminomas and non-
seminomas are preceded by GCNIS, and untreated GCNIS eventually progresses to invasive cancer [1650-
1652]. There has been a general decline in male reproductive health and an increase in testicular cancer in

140 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021