Table 1.

Published Studies on Romantic and Sexual Relationships, Body Image, and Fertility in Testicular Cancer Survivors

Study	N	Research Question(s)	Methods	Findings
Arai et al. (1997)	85	To assess the impact of different treatment modalities on sexuality and fertility in TCS	Quantitative surveys	One-fourth to one-half reported some type of sexual impairment in each group (i.e., chemotherapy with RPLND, chemotherapy, radiotherapy, and surveillance). Approximately 70% of men with RPLND reported inability of ejaculation and a greater decline in semen volume. Rates and nature of sexual dysfunction of surveillance patients were similar to other treatment groups, except for ejaculatory function. About one-third reported feeling less attractive. Although 59% of the men in the chemotherapy group desired children, only 9% had fathered children since cancer treatment. In contrast, 44% of patients in the surveillance group have fathered children since their illness started.
Brodsky (1995)	11	To examine changes in self due to the experience of TC	Qualitative, open-ended interviews	Survivors partnered at diagnosis evidenced improved physical & emotional adjustment to cancer, while those unpartnered expressed worry regarding one’s cancer history affecting future interpersonal relationships. Approximately 18% were angered/saddened regarding changes in orgasm and lack of normal ejaculation. More than half expressed concern with fertility, while others chose to purposefully ignore such issues. Many expressed regret that fertility was unnecessarily sacrificed due to a lack of knowledge regarding available fertility- preservation treatments.
Brodsky (1999)	11	To assess the experience of TC	Qualitative, open-ended interviews	Survivors’ preexisting marital conflicts were exacerbated by the TC experience, leading to relationship dissolution. Survivors reported a greater life appreciation where preexisting conflicts no longer have a place. For those survivors experiencing sexual dysfunction, they were hopeful the ejaculatory process would eventually return, yet were resolved about the sacrificial nature of treatment. All survivors had been advised, and complied, with advice to bank sperm.
Brydoy et al. (2005)	1,433	To assess TCS’ post-treatment paternity	Quantitative surveys	The paternity rate was high (71%), although many reported more difficulty with achieving paternity as compared to the general population. Mean time from diagnosis to birth of the first child was about 7 years, but varied according to treatment, with assistive reproductive technologies used by anywhere from 5% to 22% of couples who attempted conception after treatment completion.
Caffo & Amichetti (1999)	98	To explore sexual life in TCS	Quantitative surveys	Approximately 25% of TCS reported a low libido and 14% defined their sexual capacity as poor; 14% of TCS avoided sexual contact after treatment because of the disease and/or its therapies. In addition, 14% reported premature ejaculation, 2% late ejaculation, and 2% absence of ejaculation. Most TCS considered the information provided by their physician about the sexual sequelae of therapy to be insufficient.
Carroll et al. (1987)	22	To assess fertility in men with TC on a surveillance protocol	Laboratory analysis	About 45% of men had abnormal spermatogenesis on the basis of low sperm count or sperm motility. Of these men, 50% recovered normal spermatogenesis when re-evaluated 4 to 19 months later. Avoidance of RPLND seemed to spare fertility in at least a small percentage of these patients.
Chapple & McPherson (2004)	45	To understand reasons for and against seeking prosthesis	Qualitative, open-ended interviews	Reasons for opting for a prosthesis included fear of loss of masculinity, concern about self image, a desire to look normal, and a desire to feel whole again. Reasons against seeking a prosthesis included thinking the loss of a testicle was not visibly obvious, lack of impact on self image, not a long-term threat to masculinity, living with one testicle was comfortable, no desire for additional surgery, and concern about safety issues.
Dahl et al. (2007)	1,084	To explore sexual function in TCS	Quantitative surveys	TCS had significantly worse scores on ejaculatory and sexual problems in both young (20–39 years) and middle-aged (40–59 years) groups. Overall sexual problems were expressed by 38.8% of TCS versus 35.5% in the normative population. Overall sexual problems were associated with increasing age, lack of a partner, and a higher anxiety score, while ejaculation problems were associated with lack of a partner and a trend for chemotherapy and neurotoxic side effects.
Drasga et al. (1983)	28	To explore fertility after chemotherapy in TCS	Retrospective chart review	Normal sperm counts were found in 46% of TCS; only 17% were azoospermic. Thirty-two percent of TCS had impregnated their wives, resulting in 5 healthy babies, 1 spontaneous abortion, and 3 ongoing pregnancies.
Fleer et al. (2006)	350	To assess cancer-related stress symptoms in TCS	Quantitative surveys followed by qualitative, open-ended interviews with a subsample of 30	Thirteen percent of TCS reported cancer-related stress symptoms, with single survivors, those with less education, and those unemployed reporting higher levels of stress. Perceptions about the impact of cancer on current life and fear of the future were factors in the presence or absence of cancer-related stress symptoms.
Foster et al. (1993)	53	To preliminarily assess fertility in TCS who underwent RPLND	Quantitative surveys and laboratory analysis	Approximately 81% of TCS treated with nerve-sparing RPLND reported success in fathering children. Semen analyses and DNA histograms suggested fertility in >70% of TCS.
Foster et al. (1994)	201	To assess fertility in TCS who underwent RPLND	Quantitative surveys and laboratory analysis	Of those TCS who attempted pregnancy after nerve-sparing RPLND, 76% were successful. Results of semen analysis also found 75% of TCS to be in the normal range.
Girasole et al. (2007)	129	To assess frequency of sperm banking and characterize differences between men choosing to bank sperm or not	Quantitative surveys	Overall, 24% of survivors had banked sperm. Men who banked sperm were, on average, 10 years younger and less likely to have children at the time of diagnosis. The use of banked sperm was low (<10%), and many men could have children without using banked sperm.
Gritz et al. (1989)	88	To assess psychosocial sequelae in TCS and their wives or partners	Combined qualitative interviews and quantitative surveys	TCS experienced significant depletion of energy, increased fear of cancer, interference with sleep and cognitive function, and sexual difficulties during and after treatment. The moderate degree of survivor-reported sexual problems was due to problems with sexual satisfaction, sexual frequency, and erectile dysfunction.
Hannah et al. (1992)	58	To compare marital and sexual functioning of TCS and Hodgkin’s survivors and their spouses	Combined qualitative interviews and quantitative surveys	Approximately 51.5% of TCS and 55.9% of TCS’ spouses indicated special issues (i.e., financial concerns, fear of talking about cancer, possibility of recurrence, future implications) had emerged after diagnosis and treatment and these were issues they felt could not be discussed with their spouse. A substantial proportion of TCS disclosed negative changes in body image and sexual frequency. Among TCS’ spouses, 88.2% reported no decrease in their perceptions of their partners’ attractiveness, while 32.4% reported a reduction in sexual frequency.
Hartmann et al. (1999)	98	To examine types and incidences of sexual dysfunction and fertility distress in TCS	Quantitative surveys	TCS who were treated with RPLND alone or secondary resection of residual retroperitoneal tumor mass (SRRTM) reported higher incidence of sexual dysfunction, namely ejaculation problems. TCS who received both RPLND and SRRTM reported a more frequent unfulfilled wish for children. Reasons for reduced fertility included azoospermia, erectile dysfunction caused by psychosocial distress, and permanent dry ejaculation. Overall, sexual dysfunction and infertility affected approximately 20% of TCS.
Herr et al. (1998)	105	To assess long-term paternity in men with TC initially managed by surveillance	Combined qualitative interviews and quantitative surveys	About 46% of TCS fathered children while on active surveillance whereas 19% fathered children after treatment for relapse. Of the couples who attempted pregnancy on surveillance, 65% were successful.
Huddart et al. (2005)	680	To examine fertility and sexual function in TCS	Quantitative surveys	In total, 30% of TCS reported attempting conception of whom 77% were successful and a further 10 TCS were successful after infertility treatment, with an overall fertility rate of 82%. Reduced fertility was associated with previous chemotherapy treatment and elevated FSH levels. Overall sexual function was satisfactory, although there was a tendency for treated groups, as opposed to the surveillance group, to have less sexual activity and less sexual interest. Radiotherapy treatment was also associated with reduced sexual enjoyment.
Incrocci et al. (2002)	123	To assess treatment outcome, body image, and changes in sexuality after TC	Quantitative surveys	About 20% of TCS reported less interest and pleasure in sex and less sexual activity, while 17% had erectile difficulties. Cancer treatment had negatively influenced sexual life in 32% of TCS. Approximately 52% found that their body had changed after treatment.
Joly et al. (2002)	190	To assess QOL and social problems in TCS	Quantitative surveys	Health-related QOL scores did not differ significantly between TCS and healthy controls, nor did general symptom scores. Psychosocial problems were reported equally by TCS and controls. TCS reported more modification of sexual life, due mainly to decreased sexual enjoyment, decreased sexual desire, and infertility, as compared to healthy controls.
Jonker-Pool et al. (2004)	314	To assess the need for information and support in TCS versus lymphoma survivors	Quantitative surveys	More than half of TCS reported a lack of information and support concerning sexuality, at diagnosis and follow-up, while rates for patients with malignant lymphoma were lower. TCS who suffered sexual dysfunction reported extremely high needs for information and support.
Lange et al. (1983)	34	To assess the impact of RPLND and chemotherapy on fertility in TCS	Quantitative surveys and laboratory analysis	In TCS who underwent RPLND, 42% experienced spontaneous return of ejaculation. Both patients who reported trying to father a child succeeded. About 75% of TCS treated with chemotherapy experienced some return to normal spermatogenesis 18 months or more post-treatment, as evidenced by normal FSH levels and/or the presence of live sperm in the ejaculate.
Levison (1986)	46	To evaluate the impact of post-operative radio- and chemotherapy in TCS	Quantitative surveys	TCS reported no change in either libido or potency, although post-operative treatment caused sterility in 37% of TCS previously known to be fertile.
Narayan et al. (1982)	55	To assess ejaculation and fertility after RPLND in TCS	Laboratory analysis	Antegrade ejaculation had returned spontaneously in 45% of TCS. Five TCS had fathered children post-operatively. Antegrade ejaculation was induced with sympathomimetic drugs in 5 patients, 1 of whom fathered a child while taking the drugs.
Ozen et al. (1998)	140	To assess sexual and professional performance of TCS	Quantitative surveys	TCS reported that problems related to libido, erection, and ejaculation increased significantly during treatment and subsequently recovered but did not return to baseline following treatment. Unpartnered TCS reported thinking that their cancer history would be a concern for a future partner. Regarding professional lives, 22.4% of TCS thought they had better performance after treatment compared to before treatment, whereas 6.1% reported it to be worse.
Rudberg et al. (2000)	277	To assess health-related QOL in TCS	Quantitative surveys	Health-related QOL of TCS was as good or even better than that of men in the general population. Men treated with chemotherapy, either alone or in tandem with other treatments, scored less favorably on QOL. Perceived attractiveness, being fertile, having children, and living with a partner were the most important aspects of good health-related quality of life.
Rudberg et al. (2002)	669	To compare frequency of physical and psychologic symptoms in TCS as compared to general population controls	Quantitative surveys	Approximately 14% of TCS reported deteriorated sexual functioning, with these men reporting significantly more distress symptoms during the last month. Men treated with radiation therapy plus chemotherapy and/or RPLND scored lower in sexual interest and the ability to enjoy sex; they also reported more erectile difficulties. Regarding attractiveness, 15.2% reported that they felt less attractive as compared to before treatment. Men who reported decreased attractiveness experienced more symptoms than those who found themselves equally or more attractive than before treatment; they also reported lower scores on sexual functioning. TCS who perceived themselves as attractive as before had fathered children more often than those assessing themselves as more attractive or less attractive than before treatment.
Schover & von Eschenbach (1985)	121	To assess sexual and marital relationships in TCS	Quantitative surveys	Compared with healthy men, TCS reported less sexual activity, lower sexual desire, more erectile dysfunction, more difficulty achieving orgasm, reduced orgasmic intensity, and for 82%, greatly reduced semen volume. Erectile and orgasmic problems were more prevalent when radiotherapy was used and, the longer the time since treatment, the more likely TCS were to have antegrade ejaculation. About 13% of TCS were divorced/separated, and those whose marriages ended cited sexual dysfunction and cancer treatment as a significant source of marital stress.
Sheppard & Wylie (2001)	27	To assess sexual difficulties in TCS	Quantitative surveys followed by qualitative, open-ended interviews with a subsample of 7	A common theme was the perceived support of being in a committed relationship which TCS believed helped them adjust physically and emotionally to having cancer and treatment. Evidence of sexual dysfunction included few problems with impotence, loss of desire, sexual dissatisfaction, sexual frequency, and sexual communication. Body image concerns also emerged, including feeling self-conscious and anxious about whether others notice the missing testicle, as well as feeling different to others.
Spermon et al. (2003)	226	To assess prevalence of fertility/infertility in men before and after TC	Quantitative surveys	Prior to TC, 66% of couples who attempted to conceive succeeded within 1 year. After treatment, 43% of couples who attempted to conceive succeeded within 1 year. Seven couples utilized banked sperm to conceive a child after treatment.
Tamburini et al. (1989)	31	To assess impact of TC on partner relationship and sexual function	Quantitative surveys	A small subsample of TCS reported worsening of the emotional relationship with their partner following treatment. Sexual dysfunction was low overall, with most dysfunction associated with loss of ejaculation following RPLND. Anxiety scores among those TCS with reported sexual dysfunction were low, however.
Tinkler et al. (1992)	276	To assess sexual function among TCS treated with radiotherapy as compared to surveillance and normal controls	Quantitative surveys	A significant difference emerged between TCS treated with radiotherapy and and controls in erection, ejaculation, and libido, with the treated group performing less well. A deterioration in sexual function was observed with increasing age. Almost 24% of radiotherapy TCS felt disabled or disfigured by the treatment, most commonly due to the presence of only one testicle.
Tuinman et al. (2005)	259	To compare marital and sexual satisfaction of TCS and their spouses to a reference group, and to compare marital and sexual satisfaction of couples partnered during TC to couples partnered after TC	Quantitative surveys	Survivors and spouses of both couple groups reported similar marital satisfaction as couples of the reference group. Survivors and spouses of couples during TC and survivors of couples after TC reported less sexual satisfaction than the reference groups. Survivors of couples after TC reported less sexual satisfaction than survivors of couples during TC.
Tuinman et al. (2006)	129	To explore self-esteem, social support, and mental health in TCS, based on relationship status	Quantitative surveys	Social support was equal across groups, although satisfaction with support was was not. Survivors with a relationship during TC were most satisfied with support and had the highest self-esteem and mental health. Survivors with a relationship after TC reported next best functioning but had the same mental health as singles. Singles and survivors with a relationship after TC had lower mental health than a reference group of men. The difference in self-esteem between singles and survivors with a relationship during TC appeared most distinct.
Tuinman et al. (in press)	93	To assess sexual functioning during the first year after TC and examine the effect of relationship status and depressive symptoms on sexual functioning	Quantitative surveys	Orgasmic functioning, overall satisfaction, and total sexual functioning decreased between T1 (after orchiectomy) and T2 (3 months later) and increased to a level above T1 at T3 (12 months later). Levels of erectile functioning and sexual satisfaction were higher at T3 than at T1 and T2, although desire remained stable. Singles reported worse sexual functioning at all time points than partnered survivors. Depressive symptoms had small to moderate predictive power on sexual functioning at T2, but not at T3.
Turek et al. (2004)	149	To assess safety and effectiveness of a new saline-filled testicular prosthesis	Quantitative surveys	Subjective assessment of testicular appearance was significantly improved, yielding significant increases in body esteem and general self-esteem 1 year post-implant, as well as a significant increase in self-comfort during sexual activity. Prostheses were also found to be safe and well-tolerated.
Wiechno et al. (2007)	326	To assess the degree of the degree of hormonal abnormalities in TCS and the effect of these changes on TCS’ QOL	Quantitative surveys	Anxiety rate was 27%–28% while the depression rate was 15%–18%. About 40% of TCS had erectile dysfunction, with men with abnormal estradiol more prone to erectile dysfunction. Higher depression levels were found among patients with elevated LH or FSH. Elevated gonadotropins correlated with deteriorations in physical well-being.

Note. DNA = deoxyribonucleic acid; LH = luteinizing hormone; FSH = follicle stimulating hormone; QOL = quality of life; RPLND = retroperitoneal lymph node dissection; SRRTM = secondary resection of retroperitoneal tumor mass; TC = testicular cancer; TCS = testicular cancer survivors.