Sperm Retrieval for Azoospermia: TESA, TESE and Micro-TESE
Azoospermia: what does it mean?
Azoospermia means that sperm are not found in the ejaculate after an appropriate semen examination. It is an important finding, but it is not a complete explanation on its own. The team first confirms the result and then asks why sperm are absent.
The EAU recommends a full andrological assessment and careful examination of the concentrated semen sample. This can help distinguish true azoospermia from cryptozoospermia, where very small numbers of sperm may be found after centrifugation and microscopic review.EAU male infertility guideline
The first decision: obstructive or non-obstructive?
This distinction guides the conversation about sperm retrieval. It is based on the semen findings, medical history, examination, hormone results and, when indicated, genetic tests — not on one number alone.AUA/ASRM evaluation guideline
| Type | What may be happening | What the team may discuss |
|---|---|---|
| Obstructive azoospermia (OA) | Sperm production may be present, but a blockage prevents sperm from reaching the ejaculate. | Retrieval from the testis or epididymis, or reconstruction of the blockage in selected cases. |
| Non-obstructive azoospermia (NOA) | Sperm production inside the testis is reduced, patchy or absent. | A detailed andrological/genetic work-up and, when retrieval is appropriate, discussion of micro-TESE. |
The table is a map, not a personal treatment plan. The same label can have different causes, and the plan must also consider both partners’ treatment timing.
TESA, TESE and micro-TESE: how do they differ?
The procedure is chosen after the diagnosis is clarified. For men with NOA who undergo surgical retrieval, the AUA/ASRM guideline recommends microdissection TESE (micro-TESE).AUA/ASRM treatment guideline This is a moderate rather than a strong recommendation: AUA/ASRM grades it Moderate (evidence level Grade C) and the EAU grades it Weak, because the evidence comes mainly from observational studies rather than randomised trials.EAU male infertility guideline
In obstructive azoospermia, retrieval is not the only option. When the blockage is in the vas deferens or epididymis and the female partner has a good ovarian reserve, the EAU strongly recommends microsurgical reconstruction (vasovasostomy or epididymovasostomy), because it can return sperm to the ejaculate. Recanalisation after this surgery can take several months. Sperm may instead be retrieved from the testis or epididymis for ICSI when the blockage cannot be repaired, when the partner’s ovarian reserve is limited, or when the couple prefers to go directly to ICSI.EAU male infertility guideline
| Method | What it involves | Where it is usually discussed |
|---|---|---|
| TESA | A needle is used to aspirate testicular tissue or fluid. | Selected obstructive cases, depending on the examination and laboratory plan. |
| Epididymal retrieval | Sperm are collected from the epididymis, the structure where sperm mature and are stored. | Obstruction, when the epididymis is a suitable source. The exact technique may be PESA or MESA. |
| TESE | A small sample of testicular tissue is removed through an incision and examined in the laboratory. | Selected cases where testicular tissue sampling is appropriate. |
| Micro-TESE | An operating microscope helps the surgeon search for tubules more likely to contain sperm. | Confirmed NOA when surgical retrieval is planned. It still cannot guarantee that sperm will be found. |
These procedures are not different levels of the same “upgrade”. They answer different clinical questions. More complex surgery is not automatically more useful.
What should be checked before retrieval?
Before surgery, the team usually reviews the semen reports, medical and surgical history, physical examination and hormone results. Testicular volume, the presence of the vas deferens, previous surgery and the pattern of the semen findings may all change the next step.EAU male infertility diagnostic guidance
Genetic testing is selected according to the findings. In azoospermia or very severe sperm-production impairment, this may include a karyotype and Y-chromosome microdeletion testing. Genetic counselling helps explain what a result means for retrieval, future children and the wider family.AUA/ASRM evaluation guideline
The EAU sets clear thresholds for Y-microdeletion testing: it should be performed when the sperm concentration is 1 million/mL or lower (a strong recommendation), and it can be considered below 5 million/mL. CFTR testing is recommended when one or both vasa deferentia are absent. If the man has a CFTR variant or congenital absence of the vas deferens, the female partner should be tested too, because the risk for a child depends on the variants carried by both partners.EAU male infertility guideline
Genetic results can change the plan. They are not a formality to complete after the operation has already been arranged. For example, with a complete AZFa or AZFb deletion the chance of finding sperm is practically zero, and the EAU advises against TESE. With an AZFc deletion, testicular sperm can be found in about 50–75% of men, but any son conceived through ICSI will inherit the deletion.EAU male infertility guideline
Anaesthesia, recovery and possible limits
TESA, TESE and micro-TESE are performed with anaesthesia or sedation according to the technique, the centre’s protocol and your medical assessment. Your team should explain fasting, medication instructions, the expected recovery and when to ask for help.
After the procedure, temporary aching, swelling or bruising can occur. Follow the written aftercare instructions and contact the team if you have heavy bleeding, fever, worsening pain or another symptom that concerns you. The possibility of complications, including infection, bleeding or an effect on testicular function, belongs in the consent discussion. The AUA/ASRM guideline also notes that testosterone deficiency requiring treatment remains a possible risk even after micro-TESE.AUA/ASRM treatment guideline
How is retrieved sperm used in IVF?
Sperm obtained during surgery may be used fresh or cryopreserved for ICSI when there are enough viable sperm and the laboratory can use them successfully after thawing. The AUA/ASRM guideline recognises both fresh and cryopreserved sperm as options for ICSI.AUA/ASRM treatment guideline
The retrieval may be coordinated with the partner’s egg collection, or it may take place earlier with a plan for freezing. If no sperm is found, the cycle may need to be paused while the team reviews the diagnosis and the next available option. Finding sperm is an important laboratory step; it does not by itself guarantee fertilisation, embryo development or pregnancy.
A typical treatment pathway
The order differs between couples, but a plan may include:
- Review and testing: the pre-IVF assessment and male-factor work-up clarify the diagnosis.
- Planning the timing: the team coordinates retrieval with egg retrieval or prepares a freezing plan.
- Sperm retrieval: TESA, epididymal retrieval, TESE or micro-TESE is selected according to the findings.
- Laboratory fertilisation: retrieved sperm are usually used with ICSI, the IVF method in which a single sperm is injected into each egg, rather than with conventional IVF fertilisation.
- Embryo planning: embryos may be considered for embryo transfer or cryopreservation according to the medical plan.
If you are travelling to Türkiye, the local rules matter as much as the medical plan. The clinic’s IVF in Türkiye guide explains the framework for treatment with the couple’s own gametes. Egg, sperm and embryo donation and surrogacy are not available in Türkiye. If donor sperm might be needed, this should be clarified before travel, not after a procedure has been scheduled.
Dr. Aksoy’s approach
I do not start with the name of a procedure. I first want to know whether the azoospermia is confirmed, whether the pattern is obstructive or non-obstructive, and whether the genetic and hormonal information changes the plan. In NOA, micro-TESE may be the guideline-supported surgical discussion; in OA, epididymal or testicular retrieval and reconstruction may each have a place. The important part is to explain what the procedure can achieve, what it cannot answer and where uncertainty remains.
On timing: I decide whether to perform micro-TESE on the day of egg retrieval or beforehand mainly on the risk that no sperm will be found and on whether the sperm found will be enough to freeze. In a first micro-TESE for nonobstructive azoospermia with an uncertain chance of finding sperm, I prefer to operate beforehand and freeze sufficient sperm, so that the woman does not go through stimulation and egg retrieval unnecessarily. If a previous micro-TESE found only very few sperm, if I am concerned about losing live sperm after thawing, or if laboratory experience makes fresh sperm safer, I may prefer to work on the same day as egg retrieval. Guidelines accept fresh or frozen testicular sperm for ICSI, but the decision should be individualised, especially when very few sperm are obtained.
Frequently Asked Questions for Dr. Aksoy
What is the success rate of TESA and TESE?
It depends first on the type of azoospermia. In obstructive azoospermia, sperm production in the testis is usually normal, so the chance of finding sperm surgically is very high; in suitable cases it approaches 95–100%. If PESA does not provide enough sperm, the team can move on to TESA or TESE, which raises the chance further. In nonobstructive azoospermia, micro-TESE finds sperm in roughly 45–50% of men overall, but this varies greatly from one patient to another, mainly with the underlying cause, the genetic findings and whether there is focal sperm production in the testis. The sperm found is used with ICSI. After that, the chance of pregnancy depends less on the retrieval method than on the woman’s age and on egg and embryo quality.
For reference, in a series of 123 men with obstructive azoospermia treated with PESA, with rescue TESA when needed, sperm suitable for ICSI were obtained in all 157 attempts (Furtado et al., 2025); an earlier series of 146 men with obstructive azoospermia also reported retrieval in every case with percutaneous techniques (Esteves et al., 2014). The EAU guideline states that, in obstructive azoospermia, the source of the sperm and the cause of the blockage do not affect pregnancy or miscarriage rates after ICSI (EAU guideline). In nonobstructive azoospermia, a meta-analysis of 117 studies found sperm in 47% of TESE procedures overall (Corona et al., 2019).
What is the difference between TESA, TESE, PESA and MESA, and how do you choose?
PESA is the aspiration of sperm from the epididymis with a fine needle, and it can be one of the first options when the ducts are blocked. MESA means opening the epididymis surgically under a microscope to collect sperm; it is more invasive, but it can provide a large number of sperm for freezing. TESA is the aspiration of testicular tissue or sperm with a needle, and TESE is the removal of testicular tissue through a small incision. In obstructive azoospermia, PESA or MESA may be chosen when the epididymis is suitable; TESA or TESE may be preferred when sperm cannot be obtained from the epididymis or when the blockage is inside the testis. In nonobstructive azoospermia, TESA has a lower success rate, and the current EAU guideline recommends micro-TESE as the preferred method.
The EAU guideline notes that only testicular retrieval can obtain sperm when the obstruction is inside the testis, that one MESA procedure usually provides enough material for several ICSI cycles, and that TESA is no longer recommended in nonobstructive azoospermia because TESE is about twice as likely to find sperm (EAU guideline).
How long is recovery after TESA or TESE, and what side effects can occur?
After needle procedures such as PESA and TESA, most patients return to daily life quickly; mild pain, tenderness, bruising or swelling may last a few days. TESE is open surgery, so recovery can take a little longer. Even so, most patients can resume daily activities within a few days, although full comfort can take a few weeks. Bleeding or a haematoma, infection and, more rarely, damage to testicular tissue can occur; these complications are generally uncommon.
An NHS hospital patient leaflet states that local pain and swelling usually settle within a week and that bleeding and infection are rare after surgical sperm retrieval (Gateshead Health NHS Foundation Trust). The EAU guideline describes complications after TESA as uncommon, mainly minor bleeding with a scrotal haematoma and postoperative pain (EAU guideline).
If no sperm are found at TESE or micro-TESE, what are the next options?
First I review the diagnosis and the procedure itself: is this really nonobstructive azoospermia, is there a correctable hormonal or medication-related cause, is the genetic work-up complete, and was the first operation performed by an experienced micro-TESE team? If the first procedure was a conventional TESE, sperm can still be found with a salvage micro-TESE. If the first micro-TESE was also negative, a second micro-TESE can be considered in some selected patients; in recent summaries of the evidence, a second attempt found sperm in about 10–21% in most series, and more often in some selected groups. Hypospermatogenesis on the first histology is an important finding in favour of a second attempt. But I do not recommend repeat surgery to everyone: the genetic result, histology, testicular function and the quality of the first operation have to be weighed together.
In a study cited by the EAU guideline, salvage micro-TESE after a failed conventional TESE or needle aspiration found sperm in 46.5% of cases (EAU guideline); for a second micro-TESE after a failed micro-TESE, a 2025 review of nine redo series reports retrieval rates of 10–21% in most series (Elbardisi et al., 2025).
Sources
- American Society for Reproductive Medicine and American Urological Association. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II.
- American Society for Reproductive Medicine and American Urological Association. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I.
- European Association of Urology. EAU Guidelines on Sexual and Reproductive Health: Male Infertility (2026 edition).
- Corona G, Minhas S, Giwercman A, et al. Sperm recovery and ICSI outcomes in men with non-obstructive azoospermia: a systematic review and meta-analysis. Hum Reprod Update. 2019;25(6):733–757.
- Furtado TP, Zeh AK, Furtado MH. Percutaneous sperm retrieval technique: a reliable and effective sperm retrieval procedure for ICSI in patients with obstructive azoospermia. JBRA Assist Reprod. 2025;29(1):103–109.
- Esteves SC, Prudencio C, Seol B, et al. Comparison of sperm retrieval and reproductive outcome in azoospermic men with testicular failure and obstructive azoospermia treated for infertility. Asian J Androl. 2014;16(4):602–606.
- Gateshead Health NHS Foundation Trust. Surgical sperm retrieval (SSR): patient information. 2025.
- Elbardisi H, Bakircioglu E, Liu W, Katz D. Second chance in fertility: a comprehensive narrative review of redo micro-TESE outcomes after initial failure. Asian J Androl. 2025;27(3):409–415.
For education only. This page does not replace an individual assessment by a qualified fertility or andrology team.
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