Fertility preservation after bilateral severe testicular trauma

surgery, patient underwent collection of seminal fluid revealing a sperm count of 40 million; the sperm was then cryopreserved to guarantee a future reproductive potential. The serum testosterone level was too low and for this reason, a hormone replacement therapy was set. Three months after injury, the patient reported normal erectile and ejaculatory function. Five months after the injury, spermiogram showed the onset of a cryptozoospermia and ultrasound revealed a left testicular volume decrease from 10 ml to 7 ml with an inhomogeneous, hypovascular area and the right emiscrotum completely uninhabited. The topic of fertility preservation in patients with testicular trauma is noteworthy, but a literature review did not reveal consistent data discussing sperm or testicular tissue cryopreservation in patients suffering from scrotal trauma, existing only sporadic case report.4,5 Cryopreservation of sperm and testicular tissue has been successfully implemented in millions of patients suffering from conditions affecting their reproductive future. The majority of these cases are for young patients afflicted with cancer who underwent surgery that will jeopardize their reproductive ability.6,7 Unfortunately, despite progress in the refinement of fertility preservation techniques and the increase of educational resources, an information gap between patients and their healthcare teams persist.8 Therefore, this topic is often understated in clinical practice, especially when it is presented along with myriad other potential adverse effects.9 In rare clinical situations, injury may result in irreversible damage to all testicular tissues. Affected patients who are left permanently sterile require lifelong testosterone replacement therapy. Moreover, exogenous testosterone is known to suppress the release of gonadotropic hormones and may result in further Dear Editor, Testicular trauma is a frequent acquired cause of infertility; being accidents, work injuries and sport activities that are the most common causes of testicular traumas.1,2 Strangely, the issue of management of serious testicular trauma and fertility preservation has not been studied extensively before, existing only sporadic reports in international literature. Besides, no guidelines exist on fertility preservation in cases of important scrotal trauma when injury may result in irreparable damage to all testicular tissue (torsion of a solitary testis, bilateral synchronous testicular torsion, and severe bilateral scrotal trauma).3 The present case report describes the presentation of a young patient who experienced a motorbike accident with an irreparable damage to all testicular tissue in which preservation of fertility through immediate postoperative sperm cryopreservation was performed. A 31‐year‐old male presented to the emergency department with acute scrotum after a motorbike accident resulting in a severe blunt trauma against the motorbike’s fuel tank. The patient was healthy except for a history of infertility. On physical examination, the scrotum was tender and swollen with skin hematoma. Ultrasound scan (EsaOte, Genoa, Italy) with a 7.5 MHz linear‐array probe showed ruptured right testis, with interruption of normal echo‐rich line of the tunica albuginea. Testis was markedly heterogeneous (Figure 1a). Color flow Doppler ultrasound of the testicle showed a small, hypoechoic, inhomogeneous and completely avascular right testis (Figure 1b). Left testis appeared inhomogeneous, markedly hypovascular, especially at the upper pole and in the middle third where the profile was deformed. Patient was urgently taken to the operating room for a scrotal exploration: right testis appeared completely uninhabited, parenchyma was destroyed, and right orchiectomy was performed (Figure 1c). On the left side, the testis presented a disruption of the tunica albuginea with an extrusion of more than 20% of the testicular parenchyma and the rest of testis was not bleeding and did not present a necrotic appearance. The epididymis and the mediastinum testis did not appear to be involved in the injury. After careful hemostasis, the tunica albuginea was sutured in an interrupted fashion. The patient remained stable throughout the operation (total time 47 min) and did not experience significant complications during his hospital course. Adequate blood flow was consistently demonstrated in the left testicle postoperatively by serial Doppler evaluation. Ten days after LETTER TO THE EDITOR