Testicular Sperm Aspiration (TESA): Procedure, Indications, and Success Rates — Overview, Diagnosis & Treatment Options | MyMedicPlus

Testicular sperm aspiration (TESA) is a minimally invasive outpatient surgical procedure used to retrieve spermatozoa directly from the testicular parenchyma in men with azoospermia (the absence of sperm in the ejaculate). It involves insertion of a fine needle attached to a syringe into the testis under local anesthesia and aspiration of testicular tissue and fluid from which sperm are extracted and used for intracytoplasmic sperm injection (ICSI) in conjunction with in vitro fertilization (IVF). TESA is one of several surgical sperm retrieval techniques — alongside PESA (percutaneous epididymal sperm aspiration), MESA (microsurgical epididymal sperm aspiration), and micro-TESE (microdissection testicular sperm extraction) — each with different indications and sperm retrieval rates. TESA is most effective for obstructive azoospermia (OA) — where sperm production is intact but outflow is blocked — and has lower but clinically meaningful success rates for non-obstructive azoospermia (NOA). The procedure is rapid (15–30 minutes), requires minimal recovery time, and can be performed on the day of oocyte retrieval or with cryopreservation of retrieved sperm for future use.

TESA addresses azoospermia, which is broadly classified into obstructive (OA) and non-obstructive (NOA) forms. Obstructive azoospermia (the most favorable indication for TESA) arises from: congenital bilateral absence of the vas deferens (CBAVD, associated with CFTR mutations — cystic fibrosis gene); prior vasectomy; epididymal obstruction from infection (gonorrhea, chlamydia) or prior epididymitis; ejaculatory duct obstruction; or failed vasovasostomy or vasoepididymostomy. In OA, spermatogenesis is normal and the testes contain abundant spermatozoa; TESA sperm retrieval rates approach 100%. Non-obstructive azoospermia (the more challenging indication) arises from impaired spermatogenesis: Klinefelter syndrome (47,XXY — most common genetic cause of NOA), Y chromosome microdeletions (AZFa, AZFb, AZFc regions), cryptorchidism, prior chemotherapy or radiation, mumps orchitis, varicocele-associated testicular failure, and idiopathic causes. In NOA, testicular histology ranges from hypospermatogenesis to maturation arrest to Sertoli-cell-only syndrome; sperm retrieval by TESA is successful in 25–50% of cases, with micro-TESE offering higher success rates.

The primary indication for TESA is confirmed azoospermia in a man seeking fertility with his female partner. Azoospermia is confirmed by two semen analyses showing no sperm after centrifugation. Semen fructose testing distinguishes ejaculatory duct obstruction (absent fructose) from other causes. The assessment includes: reproductive hormones (FSH, LH, testosterone, prolactin) — FSH markedly elevated suggests spermatogenic failure (NOA); testicular volume (normal ≥15 mL per testis); and scrotal ultrasound. Karyotype analysis (47,XXY — Klinefelter syndrome) and Y chromosome microdeletion testing (AZFa/b/c) are performed in all NOA patients — AZFa and AZFb deletions predict zero sperm retrieval and spare the patient from futile surgery. CFTR mutation testing is performed in men with CBAVD. Testicular biopsy (in the absence of TESA) is diagnostic for NOA etiology. The female partner's ovarian reserve and reproductive evaluation proceed simultaneously, as TESA outcome and female age jointly determine IVF/ICSI prognosis. Genetic counseling is mandatory — especially for CFTR mutations and Klinefelter syndrome — to address implications for offspring.

Pre-TESA evaluation systematically characterizes the azoospermia and guides surgical planning. Two semen analyses with centrifugation confirm azoospermia. Hormonal profile (FSH, LH, testosterone, prolactin) distinguishes obstructive (normal FSH, normal testicular volume) from non-obstructive azoospermia (elevated FSH, small testicular volume). Scrotal Doppler ultrasound evaluates testicular parenchyma, detects varicocele, epididymal abnormalities, and ejaculatory duct cysts. Transrectal ultrasound (TRUS) evaluates the seminal vesicles and ejaculatory ducts for obstruction. Genetic testing — karyotype and Y chromosome microdeletion analysis — is performed in all NOA patients. CFTR mutation analysis is performed in bilateral absence of the vas deferens. The likelihood of successful sperm retrieval is assessed and communicated to the couple before proceeding. When NOA is confirmed, consideration is given to whether TESA alone or micro-TESE (which is more invasive but has higher sperm retrieval rates in NOA) is more appropriate. Sperm cryopreservation protocols and embryology laboratory preparation are coordinated before the procedure. Anesthetic assessment determines local vs. general anesthesia preference.

TESA is performed under local anesthesia (spermatic cord block) or general anesthesia as a day-case procedure. The scrotal skin is cleansed and anesthesia is administered. A fine needle (19–21 gauge) attached to a 10 mL syringe is introduced through the scrotal skin directly into the testis at the anterolateral surface. Negative pressure is applied while the needle is moved back and forth within the testicular parenchyma (fan motion) to aspirate testicular tissue and fluid. Multiple sites (typically 2–4) within the same testis or bilateral testicular sampling may be performed. The aspirated material is immediately handed to the embryologist, who examines it under the microscope to confirm sperm presence and assess motility. In obstructive azoospermia, abundant mature spermatozoa are typically identified. In non-obstructive azoospermia, fewer sperm may be found or none retrieved. Retrieved sperm are used fresh for same-day ICSI or cryopreserved (vitrification) for future use. When TESA yields no sperm in NOA, surgical micro-TESE under operating microscope is performed as a follow-up procedure — this technique examines the seminiferous tubules under magnification to identify the rare tubules with active spermatogenesis, achieving sperm retrieval rates of 50–60% in NOA compared to 25–35% for TESA alone. Postoperative care is minimal — analgesics and a scrotal support for 24–48 hours.

The prognosis for achieving parenthood following TESA is dependent on the underlying aetiology of azoospermia, the sperm retrieval rate achieved, and female partner reproductive factors. In obstructive azoospermia — where sperm production is intact and outflow is blocked — TESA achieves successful sperm retrieval in virtually 100% of cases. Fertilization rates with ICSI using testicular sperm are approximately 60–70%, and clinical pregnancy rates per embryo transfer are comparable to those achieved using ejaculated sperm. Cumulative live birth rates across multiple IVF-ICSI cycles reach 50–60% over 3 cycles in couples with obstructive azoospermia. In non-obstructive azoospermia (NOA) — where spermatogenesis itself is impaired — TESA retrieves sperm in only 25–50% of attempts; microdissection TESE (micro-TESE), which uses optical magnification to identify rare sperm-containing tubules, offers substantially higher sperm retrieval rates of 50–60% and is preferred when TESA fails. In Klinefelter syndrome (47,XXY), the most common genetic cause of NOA, sperm retrieval by TESA or micro-TESE is successful in approximately 40–60% of cases; testosterone washout before the procedure may improve retrieval rates by stimulating intratesticular FSH-driven spermatogenesis. Y chromosome AZFa or AZFb complete deletions predict essentially zero sperm retrieval and spare patients from futile surgery; AZFc deletions have a meaningful retrieval prognosis. Sperm cryopreservation allows multiple IVF cycles from a single retrieval, maximizing cumulative pregnancy success. Children conceived using testicular sperm demonstrate normal developmental outcomes. Longitudinal monitoring of testicular function is recommended for men with NOA, as spermatogenic capacity may decline further with age.

Prevention of azoospermia is condition-specific. Vasectomy-related OA is the only fully preventable common cause — men should consider vasectomy permanent and not undergo it if future fatherhood is uncertain. In boys with cryptorchidism (undescended testes), surgical orchidopexy by age 12–18 months minimizes long-term spermatogenic damage and reduces NOA risk in adulthood. Mumps vaccination prevents mumps orchitis, a potential cause of NOA. Men about to undergo gonadotoxic therapy (chemotherapy, radiation for cancer) should be offered sperm banking (cryopreservation) before treatment. Varicocele repair in adolescents with a clinically significant varicocele and volume differential may preserve testicular function. Avoidance of prolonged scrotal heat exposure, anabolic steroid use, and tobacco reduces testicular function risk. Men with CFTR mutations who are considering reproduction benefit from early specialist reproductive counseling. For Klinefelter syndrome, testosterone replacement — while improving quality of life — does not improve sperm retrieval rates; micro-TESE is optimally performed before testosterone is commenced or after washout.

Any man and couple who have been trying to conceive without success for 12 months (or 6 months if the female partner is over 35) should seek fertility evaluation including semen analysis. If the semen analysis reveals azoospermia — confirmed on a repeat sample — urgent referral to a urologist or andrologist specializing in male infertility is indicated to characterize the azoospermia and plan sperm retrieval. Men with a personal history of cancer treatment (chemotherapy, pelvic radiation), undescended testes in childhood, testicular torsion, mumps orchitis, or known genetic conditions (Klinefelter syndrome, cystic fibrosis carrier status) should proactively seek male fertility evaluation and — if cancer treatment is planned — sperm banking before treatment. Genetic counseling before TESA is important for couples when a genetic cause of azoospermia is identified, to discuss recurrence risk and implications for potential offspring. The embryology and fertility team should coordinate TESA timing with the IVF cycle for optimal synchronization.