Surgical Sperm Retrieval (TESA / TESE / PESA / micro-TESE)

Introduction

Surgical sperm retrieval is a group of short procedures used to collect sperm directly from a man’s reproductive organs — the testicles or the epididymis — when sperm cannot be found in a semen sample, or when ejaculation is not possible. The sperm that are recovered are almost always used in the same cycle, or in a later cycle, with in vitro fertilisation (IVF) and a technique called intracytoplasmic sperm injection (ICSI), where a single sperm is injected into an egg in the laboratory.

If you are reading this, you or your partner has likely already been told that natural conception is unlikely without help, often because a semen analysis showed no sperm (a condition called azoospermia) or because a previous attempt to produce a sample did not work. Surgical sperm retrieval can open a path to biological fatherhood for many men in this situation, although it does not work for everyone, and the chance of finding usable sperm depends heavily on the underlying cause.

This article explains the four main techniques used — TESA, TESE, PESA, and micro-TESE — when each is typically chosen, what the procedures involve, how recovery unfolds, and how the retrieved sperm fit into IVF treatment. It is written for the man undergoing the procedure and for his partner planning treatment together.

What Is Surgical Sperm Retrieval?

Surgical sperm retrieval is the medical name for any procedure in which sperm are obtained directly from inside the male reproductive tract, rather than from ejaculated semen. The procedures range from a simple needle aspiration done under local anaesthetic to a microsurgical operation done under general anaesthetic with the help of a high-powered operating microscope.

In a healthy male reproductive system, sperm are produced inside thousands of tiny tubes (called seminiferous tubules) in the testicles. They then mature and are stored in a coiled tube behind each testicle called the epididymis, before travelling through the vas deferens and joining other fluids to form semen at ejaculation. If sperm production is reduced, or if any part of the pathway is blocked or absent, sperm may not appear in the ejaculate even though they are present somewhere in the system. Surgical sperm retrieval is designed to reach into the system and collect whatever sperm are present.

The sperm recovered this way are almost always fewer in number and less mobile than the sperm in a normal ejaculate. Because of this, they are not used for intrauterine insemination (IUI) or for natural conception attempts. Instead, they are used with IVF and ICSI, where the embryologist selects individual sperm under a microscope and injects one into each egg.

Why Is Surgical Sperm Retrieval Performed?

Obstructive azoospermia

In obstructive azoospermia, the testicles produce sperm normally, but a blockage somewhere along the reproductive tract prevents the sperm from reaching the ejaculate. Common causes include:

• Previous vasectomy
• Congenital absence of the vas deferens (often linked to cystic fibrosis gene mutations)
• Scarring from infection, such as past epididymitis
• Damage from previous pelvic or scrotal surgery
• Ejaculatory duct obstruction

In obstructive azoospermia, the chance of finding sperm with a retrieval procedure is very high — often above 90 percent — because sperm production itself is intact.

Non-obstructive azoospermia

In non-obstructive azoospermia, the testicles themselves are not producing sperm in normal numbers. There is no blockage; the problem is at the source. Causes include:

• Genetic conditions such as Klinefelter syndrome or Y-chromosome microdeletions
• Previous chemotherapy or radiotherapy
• Undescended testicles in childhood (cryptorchidism), even if surgically corrected
• Hormonal disorders affecting the testicles
• Severe testicular injury or torsion
• Unexplained testicular failure

In non-obstructive azoospermia, sperm production is patchy. There may be small pockets of the testicle where sperm are being made even when the rest of the tissue is not producing. Finding these pockets is the central challenge, and this is the situation where micro-TESE has a clear advantage over other techniques.

Other indications

Surgical retrieval is also considered for men with:

• Ejaculatory dysfunction — for example, after spinal cord injury, after certain pelvic surgeries, or when retrograde ejaculation cannot be managed medically
• Anejaculation — inability to ejaculate despite normal sperm production
• Failed sperm retrieval from the ejaculate in men where even small numbers of sperm are not consistently obtainable
• Fertility preservation before cancer treatment in selected cases where a normal sample cannot be produced

Whether retrieval is appropriate, and which technique fits a particular situation, is decided by a fertility specialist (typically an andrologist or reproductive urologist) after a thorough workup.

Who Is a Candidate?

Before recommending surgical sperm retrieval, doctors usually carry out a careful evaluation. This is partly to confirm the diagnosis, partly to identify the cause, and partly to give a realistic estimate of the chance of finding sperm.

A typical workup includes:

• Repeat semen analysis — at least two samples, with centrifugation of the sediment, to confirm that no sperm are present
• Hormone testing — including FSH, LH, testosterone, and sometimes prolactin and estradiol
• Physical examination — checking the size and texture of the testicles, the presence of the vas deferens, and signs of varicocele
• Scrotal ultrasound — to look for blockages, varicoceles, or structural problems
• Transrectal ultrasound — in some men, to look for ejaculatory duct obstruction
• Genetic testing — karyotype, Y-chromosome microdeletion testing, and cystic fibrosis gene testing where relevant

The AUA/ASRM and EAU guidelines on male infertility describe this workup in detail. Genetic testing matters not only because it predicts retrieval success but because some genetic findings can be passed to offspring — information that the couple should have before deciding to proceed.

Couples should also have a parallel evaluation of the female partner, because the chance of a baby depends on egg quality, uterine factors, and age as much as on the sperm. A retrieval that finds sperm is only useful if the eggs in the IVF cycle are healthy enough to fertilise and develop. Many fertility units therefore plan the female stimulation cycle and the male retrieval together.

Alternatives to Surgical Sperm Retrieval

Surgical retrieval is one option, but it is not always the first step. Depending on the cause, other approaches may be considered first or alongside.

Medical treatment of the underlying cause

Some causes of azoospermia respond to medical treatment without surgery. For example:

• Hormonal causes (such as hypogonadotropic hypogonadism) can sometimes be treated with hormone therapy, which may restore sperm in the ejaculate over several months
• Retrograde ejaculation can sometimes be managed with medication, or sperm can be retrieved from urine after a modified collection
• Varicocele repair is considered in selected men with non-obstructive azoospermia, where it may improve sperm production

Surgical reconstruction

For men with obstructive azoospermia caused by a previous vasectomy, vasectomy reversal (vasovasostomy or vasoepididymostomy) is an alternative to sperm retrieval plus IVF. Reversal can allow natural conception over time and avoids the need for the female partner to go through IVF. The choice between reversal and retrieval depends on the time since vasectomy, the female partner’s age and fertility, and the couple’s preferences.

Donor sperm

For some men, particularly those with severe non-obstructive azoospermia and a very low predicted chance of finding sperm, donor sperm is a legitimate alternative. Donor sperm allows the couple to use IUI or IVF without surgery. This is a deeply personal decision and is usually discussed alongside surgical options, not instead of them. The use of donor gametes in India is governed by the ART Regulation Act 2021.

Adoption and other family-building paths

For couples for whom medical options are unlikely to succeed or are not the right fit, adoption is another path to parenthood. Fertility counsellors can help couples think through these choices.

Techniques for Surgical Sperm Retrieval

PESA — Percutaneous Epididymal Sperm Aspiration

PESA is used in men with obstructive azoospermia, where sperm are being produced normally and have collected in the epididymis behind the testicle. It is the simplest of the four techniques.

How it is done: Under local anaesthetic (sometimes with light sedation), the surgeon passes a fine needle through the skin of the scrotum into the epididymis and gently draws fluid into a syringe. The fluid is handed immediately to an embryologist, who checks it under the microscope for moving sperm. If sperm are found, the procedure can stop there. If not, the surgeon may try a different spot or move on to a testicular technique.

Time and recovery: PESA usually takes 15 to 30 minutes. Most men go home the same day with mild soreness and bruising for a few days.

When it is chosen: Obstructive azoospermia — for example, after vasectomy, congenital absence of the vas, or post-infection obstruction. PESA is generally not used for non-obstructive azoospermia, where the epididymis is unlikely to contain sperm.

Trade-offs: PESA is quick, less invasive, and avoids cutting into the testicle. The amount of sperm recovered is sometimes small, and repeat procedures may be needed. Some units prefer TESA or open techniques because the recovered sperm tend to be more numerous.

TESA — Testicular Sperm Aspiration

TESA collects sperm directly from the testicle using a needle.

How it is done: Under local anaesthetic, the surgeon passes a needle through the scrotal skin into the testicle and aspirates a small amount of tissue and fluid. As with PESA, the embryologist examines the sample immediately. Multiple passes into different parts of the testicle may be made to improve the chance of finding sperm.

Time and recovery: Similar to PESA — usually under an hour, with same-day discharge and a few days of scrotal soreness.

When it is chosen: TESA is commonly used in obstructive azoospermia, sometimes as a first step before considering open techniques. It can also be used in selected men with non-obstructive azoospermia, but the chance of finding sperm in non-obstructive cases is significantly lower than with micro-TESE.

Trade-offs: TESA is straightforward and minimally invasive. The yield can be low, and in non-obstructive azoospermia it may miss pockets of sperm production that a more thorough technique would find.

TESE — Testicular Sperm Extraction

TESE involves taking small pieces of tissue from the testicle through a surgical opening, rather than just aspirating with a needle. It is sometimes called “conventional TESE” to distinguish it from the microsurgical version (micro-TESE) described below.

How it is done: Under local, regional, or general anaesthetic, the surgeon makes a small incision in the scrotum, exposes the testicle, and removes one or several small samples of testicular tissue. The tissue is broken down in the laboratory, and the embryologist searches it for sperm. The incisions are then closed with absorbable stitches.

Time and recovery: The procedure typically takes 30 to 60 minutes. Most men go home the same day. Recovery includes a few days of soreness and swelling and usually one to two weeks before returning to vigorous activity.

When it is chosen: TESE is used in both obstructive and non-obstructive azoospermia. In obstructive cases, it reliably finds sperm. In non-obstructive cases, it finds sperm in some men but is less thorough than micro-TESE in searching the testicle.

Trade-offs: TESE is more invasive than TESA and PESA but yields more tissue and therefore more sperm. Because it samples tissue somewhat blindly, it may miss localised pockets of sperm production in men with severely impaired spermatogenesis.

Micro-TESE — Microsurgical Testicular Sperm Extraction

Micro-TESE is a more elaborate version of TESE that uses an operating microscope to identify the seminiferous tubules most likely to contain sperm.

How it is done: Under general anaesthetic, the surgeon makes a longer incision in the scrotum and opens the testicle along its length to expose the seminiferous tubules. Using an operating microscope at high magnification (typically 15–25 times), the surgeon examines the tubules and selects those that look larger and more opaque — features associated with active sperm production. Small samples of these specific tubules are removed and handed to the embryologist for searching. The testicle and scrotum are then closed in layers.

Time and recovery: Micro-TESE typically takes two to four hours, sometimes longer, especially if both testicles are explored. Most men go home the same day or the next day. Recovery involves more soreness and swelling than the less invasive techniques, with about two weeks before returning to normal activity.

When it is chosen: Micro-TESE is the technique most often recommended for non-obstructive azoospermia, particularly when other techniques have failed or when the predicted chance of finding sperm is low. Major society guidelines, including those of the AUA/ASRM and EAU, describe micro-TESE as the preferred approach in non-obstructive azoospermia because it has been shown to find sperm in a meaningful proportion of men where conventional techniques do not.

Trade-offs: Micro-TESE finds sperm in roughly 40 to 60 percent of men with non-obstructive azoospermia, depending on the underlying cause — higher than conventional TESE in most published comparisons. Because it removes less tissue overall and is more selective, it tends to preserve testicular function and hormone production better than wider-sampling techniques. The trade-offs are that it requires general anaesthetic, takes longer, needs a surgeon with specific microsurgical training, and needs an embryology laboratory experienced in searching tiny samples.

Choosing among the techniques

The choice depends mainly on the cause:

• For obstructive azoospermia, PESA, TESA, or conventional TESE all work well; the choice often comes down to surgeon preference and what is least invasive for the patient.
• For non-obstructive azoospermia, micro-TESE is generally favoured by current guidelines because of its higher sperm-finding rate, although it requires specific expertise.
• For men with ejaculatory dysfunction but normal sperm production, simpler techniques such as TESA are often enough.

The decision is made together with a fertility specialist who has reviewed the workup in detail.

Preparing for the Procedure

Preparation for surgical sperm retrieval is usually straightforward, but a few things matter.

Timing with the female partner’s cycle. If fresh sperm are to be used in the same IVF cycle, the retrieval is scheduled close to or on the day of egg collection. This requires the female partner to start ovarian stimulation knowing the retrieval will be attempted. If frozen sperm from a previous retrieval is being used, timing is more flexible.

Pre-operative tests. Standard pre-anaesthetic checks may include blood tests, ECG, and review by an anaesthetist if general anaesthetic is planned. Screening for infections (HIV, hepatitis) is required for use of gametes in a fertility laboratory.

Medications and supplements. Blood-thinning medications, certain herbal supplements, and anti-inflammatory drugs may need to be stopped before surgery. The surgical team will provide a specific list.

Fasting. If general anaesthetic is planned (typical for micro-TESE), no food or drink for several hours before surgery, according to the anaesthetist’s instructions.

Shaving and hygiene. Some units ask the patient to clip scrotal hair before surgery; others do this in the operating theatre.

Counselling. Most fertility units offer a counselling session before retrieval, especially before micro-TESE. This covers the realistic chance of finding sperm given the diagnosis, what happens if no sperm are found, the option of donor sperm, and genetic considerations where relevant.

Backup planning. When sperm-finding is uncertain (non-obstructive cases), some couples plan in advance for what will happen if no sperm are retrieved on the day of egg collection — for example, whether donor sperm will be used, the eggs will be frozen, or the cycle will be cancelled. Making this decision in advance reduces pressure on the day.

What Happens on the Day

The exact experience depends on the technique, but the general flow is similar.

The patient arrives at the hospital or day-surgery unit, changes into a gown, and meets the surgical and anaesthetic team. An intravenous line is placed. For local anaesthetic procedures (PESA, TESA, sometimes TESE), a sedative may be given to help with anxiety, and the scrotum is numbed with injected anaesthetic. For micro-TESE and many TESE procedures, general anaesthetic is used and the patient is asleep throughout.

In the operating room, the scrotum is cleaned and draped. The surgeon performs the chosen technique. Tissue or fluid samples are passed immediately to an embryologist, who searches them under a microscope in real time. If sperm are found, the search may be stopped at that point or continued to collect more. If no sperm are found, the surgeon may extend the procedure to a different technique or different part of the testicle, depending on what was agreed in advance.

If the retrieval is timed with the partner’s egg collection, the retrieved sperm are taken straight to the IVF laboratory for ICSI. If not, the sperm are frozen (cryopreserved) for use in a later cycle. Frozen sperm from retrieval procedures can be stored for years and used in multiple subsequent attempts.

Recovery is generally quick, especially for needle-based techniques. Soreness, mild swelling, and bruising in the scrotum are normal and usually settle over several days.

Days 1–3: The scrotum is sore and may be bruised. Most men rest at home and use simple pain relief (paracetamol; anti-inflammatories if allowed by the surgeon). Ice packs over a cloth, applied to the scrotum for short periods, reduce swelling. Wearing supportive underwear is recommended.

Days 3–7: Pain settles. Light activity is usually fine. Showers are allowed; baths and swimming should wait until any incisions have healed.

Week 2: Most men return to normal work and gentle exercise. Vigorous exercise, heavy lifting, and sexual activity are usually delayed for one to two weeks after needle techniques and two to three weeks after open or microsurgical procedures.

Stitches: Where used, they are absorbable and do not need removal.

Warning signs: Contact the surgical team if there is increasing pain, severe swelling, fever, redness spreading on the scrotum, or pus from an incision.

Most men feel fully recovered within two to four weeks. Hormone levels can dip after micro-TESE in particular, and testosterone is sometimes checked again a few months later, especially in men who already had borderline levels before surgery.

Risks and Complications

Surgical sperm retrieval is generally safe, but every procedure carries some risk.

• Bleeding and bruising. Some scrotal bruising is expected. A larger blood collection (haematoma) is uncommon but may need drainage.
• Infection. Wound or scrotal infection is uncommon. Antibiotics may be given before or after surgery in some cases.
• Pain. Most pain is mild and short-lived. A small number of men have longer-lasting scrotal discomfort.
• Damage to testicular tissue. Removing tissue, particularly in conventional TESE, can leave small areas of scarring. Micro-TESE is designed to minimise this by removing less tissue.
• Reduction in testosterone production. Especially after micro-TESE, testosterone levels can drop in the months after surgery. In most men they recover, but a few develop persistent low testosterone and need monitoring or treatment.
• Anaesthetic risks. Where general anaesthetic is used, standard anaesthetic risks apply. These are low in healthy patients.
• No sperm found. The most significant “risk” for men with non-obstructive azoospermia is that no sperm are found despite a thorough search. This is not a complication in the surgical sense, but it is a real and difficult outcome that the couple should be prepared for.

Risks vary by technique. Needle-based procedures (PESA, TESA) carry the lowest risk of bleeding and tissue damage but may also yield less sperm. Open and microsurgical techniques carry slightly more risk but a better chance of success in difficult cases.

How the Retrieved Sperm Are Used

Sperm from a surgical retrieval are almost always used with ICSI. The embryology team picks individual sperm under a high-magnification microscope, selects those that look most healthy, and injects one into each mature egg. Surgically retrieved sperm are often immature or poorly motile compared with ejaculated sperm, which is why ICSI — rather than conventional IVF — is the standard.

Fertilisation rates with retrieved sperm can be similar to those with ejaculated sperm when ICSI is used, though they are influenced by the cause of azoospermia and the quality of the sperm found. Embryos that develop are then cultured for a few days and transferred to the uterus, either in the same cycle (fresh transfer) or after freezing (frozen transfer).

If multiple sperm are retrieved, the extras are usually frozen for use in future cycles. This is particularly valuable in non-obstructive azoospermia, where finding sperm again in a second procedure cannot be guaranteed.

Success Rates and What Affects Them

“Success” in this context has two layers. The first is whether sperm are found at all. The second is whether the IVF cycle that uses those sperm results in a live birth.

Sperm-finding rates are strongly tied to the cause of azoospermia:

• In obstructive azoospermia, sperm are typically found in over 90 percent of cases, regardless of which technique is used.
• In non-obstructive azoospermia, sperm are found in roughly 40 to 60 percent of men using micro-TESE, with lower rates using TESA or conventional TESE. The specific number depends on the underlying cause — for example, men with Klinefelter syndrome and men with prior chemotherapy have different prospects.

Pregnancy and live birth rates after a successful retrieval depend on factors that have little to do with the retrieval itself — especially the age and egg quality of the female partner, the embryology laboratory’s practices, and the number of embryos transferred over the course of treatment. As with IVF in general, the chance of a live birth per cycle declines steeply with female age, particularly through the late 30s and 40s.

Because of the wide variability, the most useful estimate is a personalised one from the fertility specialist looking after the couple, based on the specific diagnosis, hormone profile, genetic findings, and the female partner’s assessment.

Genetic and Family-Planning Considerations

Some causes of azoospermia carry genetic implications for the children conceived. Y-chromosome microdeletions, for example, are passed from father to male offspring and can cause the same fertility problem in the next generation. Cystic fibrosis gene mutations linked to congenital absence of the vas deferens have implications if the female partner is also a carrier. Klinefelter syndrome involves an extra X chromosome and has wider health implications.

Major society guidelines recommend that men with non-obstructive azoospermia or with congenital absence of the vas deferens have genetic testing before retrieval, and that couples have access to genetic counselling. This is so that decisions about retrieval, IVF, and preimplantation testing can be made with full information.

Preimplantation genetic testing of embryos is available for some specific genetic conditions and is discussed during fertility planning where relevant.

Emotional and Practical Considerations

Surgical sperm retrieval, especially for non-obstructive azoospermia, is emotionally weighty in ways that are easy to underestimate. The procedure itself is short, but the decision around it — whether sperm will be found, whether IVF will succeed, what to do if no sperm are found, whether to consider donor sperm or adoption — sits at the centre of a couple’s plans for the family they hope to have.

Several things help:

• Talking about the “what if” in advance. Couples who discuss the possibility of no sperm being found, and what they would do, often find the day of the procedure less overwhelming.
• Counselling. Fertility counsellors are trained to help with these specific conversations. Many units offer sessions before and after retrieval.
• Privacy. Many men prefer not to discuss the details widely. Choosing one or two trusted people to share with can ease the isolation without exposing the couple to unwanted comment.
• Time for the partner. The female partner, who is going through IVF stimulation, often carries her own emotional load. The retrieval day belongs to both partners.

What Choosing a Fertility Centre Involves

Surgical sperm retrieval is technically dependent on three things working well together: the surgeon’s skill, the embryology laboratory’s ability to search and process small samples, and the IVF unit’s overall standards. Things that couples and their referring doctors usually look at include:

• Whether the surgeon has specific training in andrology and microsurgery, particularly if micro-TESE is being considered
• How often the unit performs the specific procedure being planned
• The embryology laboratory’s experience with searching testicular samples for sperm, including on the day of egg collection
• The unit’s approach to backup plans (such as donor sperm) if no sperm are found
• Genetic counselling availability
• Cryopreservation facilities for storing retrieved sperm

These are practical conversations to have with the fertility unit before booking the procedure.

Frequently Asked Questions

Is surgical sperm retrieval painful?

The procedures are done under anaesthetic, so they are not painful at the time. Afterwards, most men describe scrotal soreness similar to a mild groin injury for a few days. Pain relief and supportive underwear help. Severe pain is uncommon and should be reported to the surgical team.

Will I need general anaesthetic?

PESA and TESA are usually done under local anaesthetic, sometimes with sedation. Conventional TESE may be done under local, regional, or general anaesthetic. Micro-TESE is almost always done under general anaesthetic because it takes longer and requires the patient to remain completely still.

How much sperm is needed for IVF?

Because ICSI uses one sperm per egg, even a very small number of viable sperm can be enough. Embryologists routinely work with the small quantities recovered from testicular samples. Where larger numbers are found, the extras are frozen for future cycles.

Can the retrieved sperm be frozen?

Yes. Most fertility units freeze retrieved sperm whenever quantity allows, particularly in non-obstructive cases where a second retrieval may not be successful. Frozen sperm can be stored for years and used in multiple cycles.

What happens if no sperm are found?

This is the hardest outcome and one that the couple should be prepared for in advance, especially in non-obstructive cases. Options include using donor sperm (which can be discussed before or after the procedure), considering adoption, or, in some specific cases, repeat retrieval at a later date if hormone treatment or other interventions might improve the chance. A fertility counsellor can help with the decision.

Will surgical retrieval affect my testosterone levels?

Most men’s testosterone is unchanged or only briefly dips. After micro-TESE, the dip can last longer and a small number of men develop persistent low testosterone, which can be monitored and treated if needed. The risk is higher in men who already had low or borderline testosterone before surgery.

How soon can I try again if the first retrieval fails?

Most surgeons wait at least three to six months between retrieval attempts to allow the testicle to recover and to give hormone levels time to settle. The interval is decided case by case.

Does surgical sperm retrieval affect future natural fertility?

For men with azoospermia, natural fertility was already absent or very limited before retrieval. The procedure does not generally make this worse. For men with very low sperm counts who happen to undergo retrieval, the impact on ejaculated sperm production is usually small.

Is there a difference in baby outcomes between sperm from ejaculate and sperm from a surgical retrieval?

When ICSI is used, fertilisation and pregnancy outcomes are broadly comparable, though they can vary with the underlying cause. Studies have not shown a clear increase in birth defects above the small background risk seen with ICSI in general. Couples with specific genetic findings should discuss tailored risks with a genetic counsellor.

Can the procedure be repeated?

Yes. Repeat retrievals are possible and are sometimes planned in advance — for example, when more sperm are needed for future cycles. The chance of finding sperm at a repeat micro-TESE in a man whose first procedure was negative is lower than at the first attempt, but it is not zero.

Conclusion

Surgical sperm retrieval is a set of carefully developed techniques that can make biological fatherhood possible for many men who cannot produce sperm in their ejaculate. For obstructive azoospermia, the procedure is highly reliable; for non-obstructive azoospermia, particularly with micro-TESE, it offers a meaningful chance where other approaches do not. The right technique, the realistic chance of success, and the supporting decisions — about IVF, genetic testing, and backup plans — are best worked out together with a fertility specialist who has reviewed the full picture for both partners.

Whatever the outcome of any individual procedure, having clear information, time to discuss the options, and support around the harder possibilities tends to make this stage of treatment less overwhelming to navigate.