Testicular Sperm Extraction (TESE) — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Testicular sperm extraction (TESE) is a surgical procedure to retrieve sperm directly from testicular tissue in men with azoospermia (complete absence of sperm in the ejaculate) who wish to father biological children using in vitro fertilisation (IVF) with intracytoplasmic sperm injection (ICSI). ICSI — in which a single retrieved sperm is injected directly into an egg — allows fertilisation even with very small numbers of surgically retrieved sperm.

Two main variants of TESE are performed: conventional TESE (cTESE) — removal of one or more small testicular biopsy cores (1–2 mm) through a small scrotal incision under local or general anaesthesia; and microsurgical TESE (micro-TESE) — the gold standard for non-obstructive azoospermia — in which the testis is opened and systematically examined under 15–25× operating microscope magnification to identify and selectively harvest the dilated, sperm-containing seminiferous tubules (which appear slightly larger and more opaque than non-productive tubules), retrieving the maximum number of sperm while removing the minimum amount of testicular tissue.

Micro-TESE was developed by Dr Peter Schlegel at Cornell University in 1999 and has significantly improved sperm retrieval rates for non-obstructive azoospermia compared to conventional biopsy techniques, with less post-operative testicular damage.

TESE is indicated for men with azoospermia (no sperm in the ejaculate) who have exhausted or are not candidates for non-surgical sperm retrieval methods. Azoospermia is classified into two types that determine which TESE approach is preferred:

Obstructive azoospermia (OA) — where sperm production is normal but blocked from reaching the ejaculate due to obstruction of the epididymis, vas deferens, or ejaculatory ducts. Causes include previous vasectomy (the most common), congenital bilateral absence of the vas deferens (CBAVD, a CFTR gene mutation seen in men with cystic fibrosis), epididymal blockage from past infection, and failed vasectomy reversal. In OA, sperm are abundant in the testis and epididymis; percutaneous sperm aspiration (PESA or TESA) is often sufficient, with TESE as a back-up if aspiration yields insufficient sperm.

Non-obstructive azoospermia (NOA) — where sperm production is severely impaired or absent at the testicular level. Causes include Klinefelter syndrome (47,XXY — the most common genetic cause), Y chromosome microdeletions (AZFc deletions most amenable to TESE), cryptorchidism, orchitis (including mumps orchitis), chemotherapy or radiotherapy gonadotoxicity, and idiopathic primary testicular failure. Micro-TESE achieves sperm retrieval in 40–60% of NOA cases — a remarkable result given these patients have severe impairment of spermatogenesis.

Pre-procedure assessment includes FSH, LH, testosterone levels (to assess hormonal axis function), testicular volume by orchidometry or ultrasound, karyotype, and Y-chromosome microdeletion analysis. These tests help predict likelihood of successful sperm retrieval.

Micro-TESE technique: The procedure is performed under general or spinal anaesthesia, with the patient in the supine position and the scrotum draped in the operative field. A 3–4 cm longitudinal scrotal incision exposes the tunica vaginalis. The testis is delivered and the tunica albuginea opened with a wide incision. The operating microscope (15–20× magnification) allows the surgeon to directly inspect the seminiferous tubules and identify larger, more opaque (often yellowish) dilated tubules that are most likely to contain sperm.

Targeted biopsies of these promising tubule clusters are excised with micro-scissors and immediately examined under a phase-contrast microscope by an embryologist in the adjacent laboratory. Multiple biopsies from different areas of the testis may be taken, guided by microscopic appearance. If sperm are found, retrieval is complete; if not, additional sampling continues. The tunica is closed with absorbable sutures and the scrotum repaired. Retrieved sperm are used fresh for same-day ICSI or cryopreserved for future cycles. Operative time: 60–120 minutes. Coordinated with the female partner's egg collection cycle. The embryologist immediately examines each biopsy under a phase-contrast microscope at 200× magnification, reporting sperm presence, motility grade, and estimated number to guide the surgeon.

Micro-TESE provides the highest sperm retrieval rates currently available for non-obstructive azoospermia. Published series consistently report sperm retrieval rates of 40–60% for NOA overall, with specific aetiology-dependent rates: Klinefelter syndrome 40–60%; AZFc microdeletion 50–70%; hypospermatogenesis 70–80%; and maturation arrest 20–40% depending on the level of arrest.

When sperm are successfully retrieved, ICSI fertilisation rates are 60–70%, blastocyst development rates are 40–60%, and clinical pregnancy rates per transfer are 40–50% depending on female partner age and embryo quality. This means that of all men who undergo micro-TESE, approximately 25–40% achieve a biological child.

For obstructive azoospermia (vasectomy, CBAVD), sperm retrieval rates exceed 90%, and with cryopreservation, retrieved sperm can support multiple ICSI cycles from a single procedure. Micro-TESE's selective approach minimises testicular tissue removal compared to multiple random biopsies, preserving testosterone-producing Leydig cells and maintaining endocrine function — a major advantage over earlier conventional TESE approaches that removed larger tissue volumes.

Micro-TESE carries the risks of general or spinal anaesthesia and local complications from testicular surgery. The most significant concern is long-term testosterone production. Temporary testosterone reduction occurs in 20–40% of men in the 3–6 months following micro-TESE, with testosterone returning to pre-procedure levels in the majority by 12 months. Permanent testosterone deficiency requiring replacement therapy is reported in approximately 5–10% of cases, most commonly in Klinefelter syndrome patients who already have marginal testosterone production.

Haematoma (bleeding within the scrotum) occurs in 2–5% and usually resolves spontaneously; significant haematomas may require surgical evacuation. Infection of the wound or epididymis is uncommon (less than 2%) and managed with antibiotics. Testicular atrophy (shrinkage) may result from significant tissue removal or haematoma formation. The procedure carries a failed sperm retrieval rate of 40–60% in non-obstructive azoospermia — patients must be comprehensively counselled that despite the surgical procedure, no sperm may be found and IVF/ICSI will not be possible with own genetic material.

Micro-TESE is typically performed as a day-case or overnight-stay procedure. Scrotal discomfort and swelling are expected for 3–7 days. Scrotal support (tight underwear or athletic supporter) is recommended for 2 weeks. Ice packs applied for 20 minutes every few hours for the first 48 hours reduce swelling. Paracetamol and ibuprofen manage post-operative pain adequately in most patients.

Activity restrictions include: avoidance of strenuous exercise and heavy lifting for 2–3 weeks; sexual abstinence for 1–2 weeks; showering (with waterproof dressing protection) from day 2. Sutures are absorbable and do not require removal. Most men return to office-based or sedentary work within 3–5 days.

Serum testosterone levels should be checked at 3–6 months post-procedure as micro-TESE can cause a temporary reduction in testosterone production in some patients from devascularisation of testicular tissue. Testosterone supplementation may be needed if levels fall below the normal range. If sperm were cryopreserved, the couple proceeds with an ICSI cycle according to the fertility treatment protocol.