Percutaneous Epididymal Sperm Aspiration (PESA) — Cost, Top Hospitals & Success Rates | MyMedicPlus

Percutaneous Epididymal Sperm Aspiration (PESA) is a minimally invasive outpatient procedure used to retrieve sperm directly from the epididymis in men who have no sperm in their ejaculate (azoospermia) due to a blockage in the reproductive tract. The retrieved sperm are used in intracytoplasmic sperm injection (ICSI) — a form of in vitro fertilisation (IVF) in which a single sperm is injected directly into an egg to achieve fertilisation.

The epididymis is a tightly coiled tube, approximately 6 metres long when uncoiled, which lies on the surface of each testis. It is where sperm mature after production in the seminiferous tubules of the testis and where they are stored before ejaculation. In men with obstructive azoospermia — caused by blockage or absence of the vas deferens, previous vasectomy, or post-infective obstruction — sperm accumulate in the epididymis but cannot be ejaculated. PESA directly accesses this reservoir.

The procedure was described and refined by the London fertility pioneer Ian Craft and colleagues in the early 1990s alongside the development of ICSI itself, which made it possible for the first time to achieve fertilisation with small numbers of sperm — including the non-motile or poorly motile sperm sometimes retrieved by PESA. Under local anaesthesia with or without light sedation, a fine needle (21–23 gauge) is passed percutaneously (through the scrotal skin) into the head or body of the epididymis. Gentle aspiration draws out epididymal fluid containing sperm, which is immediately assessed by an embryologist under the microscope. If motile sperm are identified, the procedure is complete. If not, the needle is repositioned or additional aspirations are performed from different parts of the epididymis. The procedure takes 15–30 minutes and requires no surgical incision.

PESA is specifically indicated for men with obstructive azoospermia (OA) — a condition in which sperm production in the testis is normal but sperm cannot exit due to a physical blockage. It is not suitable for non-obstructive azoospermia (NOA), where the testes fail to produce sperm adequately.

Causes of obstructive azoospermia where PESA is applicable:

• Congenital Bilateral Absence of the Vas Deferens (CBAVD): The most common congenital cause. The vas deferens — the tube connecting the epididymis to the ejaculatory duct — is absent from birth. CBAVD is closely associated with mutations in the CFTR gene (cystic fibrosis transmembrane conductance regulator). Men with CBAVD produce sperm normally in the testis and accumulate them in the epididymis, making PESA highly effective. Both partners should undergo CFTR genetic screening before proceeding, as CBAVD-associated gene mutations can be passed to children.
• Vasectomy: Men who have undergone vasectomy and either wish to conceive without undergoing surgical reversal, or in whom vasectomy reversal has failed or is not technically feasible due to the interval since vasectomy (>10–15 years), are excellent candidates for PESA.
• Post-infective epididymal obstruction: Sexually transmitted infections, particularly gonorrhoea and chlamydia, can cause scarring and obstruction of the epididymis, leading to obstructive azoospermia.
• Failed vasectomy reversal: When microsurgical vasectomy reversal (vasovasostomy or vasoepididymostomy) has been attempted but natural semen return has not been achieved, PESA with ICSI provides an alternative pathway to parenthood.
• Ejaculatory duct obstruction: Blockage at the level of the ejaculatory ducts, sometimes due to Mullerian duct cysts or post-inflammatory scarring; may be treated surgically (TURED) but PESA provides an alternative.

A thorough andrological evaluation is required before PESA to confirm the diagnosis of obstructive azoospermia and to optimise the chances of successful sperm retrieval.

Diagnostic work-up before PESA:

• Semen analysis (x2): Azoospermia confirmed on at least two samples with centrifugation of the pellet to exclude rare cryptic sperm
• Hormonal profile: FSH, LH, total testosterone, prolactin — in obstructive azoospermia, FSH and LH are normal (indicating intact spermatogenesis); elevated FSH suggests testicular failure (NOA)
• Testicular volume: Normal testicular size bilaterally on examination and ultrasound indicates preserved spermatogenesis — a positive predictor for PESA success
• Scrotal ultrasound: Identifies presence/absence of vas deferens, epididymal dilation, varicocele, or testicular pathology
• Genetic testing: CFTR gene mutation analysis for CBAVD patients (and their partner); Y-chromosome microdeletion analysis to exclude AZFa/AZFb deletions (which indicate primary testicular failure)
• Partner assessment: Ovarian reserve (AMH, antral follicle count), tubal patency — PESA is only performed in conjunction with IVF/ICSI, which requires partner assessment

Ideal PESA candidates:

• Confirmed obstructive azoospermia with normal hormonal profile and testicular volume
• Partner medically suitable for IVF/ICSI ovarian stimulation
• No active scrotal or epididymal infection
• Fully informed consent after counselling covering sperm retrieval success rates, IVF/ICSI success rates, genetic implications, and cryopreservation options

PESA is NOT appropriate for: Non-obstructive azoospermia (Sertoli-cell-only syndrome, maturation arrest, testicular failure — indicated by high FSH and small testes), where testicular sperm extraction (TESE or microTESE) is required.

Several sperm retrieval techniques are available for azoospermic men. The choice depends on whether the azoospermia is obstructive or non-obstructive, the patient's anatomy, prior surgical history, and centre expertise.

PESA (Percutaneous Epididymal Sperm Aspiration) — the simplest option: A 21–23 gauge butterfly needle or fine-bore needle is attached to a syringe. The epididymis is held steady between the surgeon's fingers. The needle is advanced percutaneously into the epididymal head or body under local anaesthetic. Gentle negative pressure aspirates epididymal fluid. The aspirate is examined by the embryologist at chairside. Multiple passes may be made. Typical yield: 50,000–5,000,000 sperm per aspiration in obstructive cases. Motile sperm recovered in 50–70% of aspirations.

MESA (Microsurgical Epididymal Sperm Aspiration): Open microsurgical procedure under general or regional anaesthesia. The epididymis is exposed through a scrotal incision. An operating microscope allows direct visualisation of individual epididymal tubules, which are incised and the contents aspirated. Provides the highest sperm yield (sufficient for multiple ICSI cycles and cryopreservation). Preferred if PESA fails or if large numbers of sperm are needed for banking. Requires microsurgical expertise.

TESA (Testicular Sperm Aspiration): Percutaneous needle biopsy of the testis itself. Used when PESA fails or as a primary technique. Retrieves smaller numbers of sperm. Suitable for both obstructive and selected non-obstructive azoospermia cases.

TESE (Testicular Sperm Extraction) and microTESE: Open testicular biopsy. TESE retrieves random biopsies; microTESE uses an operating microscope to identify dilated seminiferous tubules likely to contain sperm — the gold standard for non-obstructive azoospermia. Not typically required for CBAVD or vasectomy-related OA.

Vasectomy reversal (vasovasostomy or vasoepididymostomy): Microsurgical re-anastomosis of the vas deferens, allowing natural sperm passage and potential natural conception. Success rates decline with interval since vasectomy: >90% at <3 years; 30–40% at >15 years. Offers the advantage of natural conception without ongoing IVF cycles. The choice between reversal and PESA+ICSI depends on partner age, ovarian reserve, interval since vasectomy, and cost preference.

PESA is the least invasive and most accessible sperm retrieval technique, offering several advantages in the management of obstructive azoospermia.

Procedural advantages:

• No surgical incision required — performed with a fine needle through the scrotal skin
• Local anaesthesia with or without light oral sedation; no general anaesthesia required for the procedure itself (though concurrent synchronised egg retrieval from the partner may be performed under sedation)
• Office-based or outpatient procedure: 15–30 minutes; patient returns home same day
• Lower cost than MESA, TESE, or microsurgical procedures
• Repeatable: can be performed multiple times if initial retrieval is successful and cryopreservation is used

Clinical outcomes:

• Sperm retrieval rate: 50–70% per aspiration attempt in confirmed obstructive azoospermia. Higher rates (70–85%) reported in CBAVD patients at experienced centres.
• ICSI fertilisation rate with PESA sperm: 50–70%, comparable to ICSI with ejaculated sperm
• Clinical pregnancy rate per ICSI cycle using PESA sperm: 35–55% in women under 37 with good ovarian reserve — equivalent to outcomes with ejaculated sperm ICSI
• Cumulative live birth rate: 60–75% over multiple cycles using cryopreserved PESA sperm

Cryopreservation: Excess motile sperm retrieved at PESA can be cryopreserved and used in future ICSI cycles, eliminating the need for the male partner to undergo another retrieval procedure for each IVF cycle. Modern cryopreservation of epididymal sperm maintains viability for 10 or more years.

Outcome equivalence to more invasive techniques: Multiple studies confirm that ICSI outcomes using PESA-derived, MESA-derived, and TESA-derived sperm are broadly equivalent in obstructive azoospermia, supporting PESA as the preferred first-line approach due to its minimal invasiveness.

PESA is one of the safest procedures in reproductive medicine, with a low complication profile. However, the most significant concern is failure to retrieve usable sperm, necessitating escalation to more invasive techniques.

Primary risk — failed sperm retrieval (30–50%): PESA may fail to retrieve motile sperm even in men with confirmed obstructive azoospermia. This can occur when epididymal fluid contains predominantly dead or non-motile sperm, when the epididymis is fibrosed from prior infection or multiple previous aspirations, or when the spermatogenic process — despite appearing normal hormonally — is subtly impaired. Failed PESA should trigger immediate escalation to MESA (if an operating microsurgeon is available) or TESA on the same day, particularly if the partner is simultaneously undergoing egg collection.

Haematoma (scrotal bruising and swelling): 5–10%: Accumulation of blood at the aspiration site within the scrotum. Usually minor and self-resolving over 1–2 weeks with scrotal support and ice packs. Rarely requires surgical drainage.

Epididymitis: <2%: Post-procedural infection of the epididymis presenting with scrotal pain, swelling, and fever. Treated with antibiotics (ciprofloxacin or doxycycline). Prophylactic antibiotics are given pre-procedure at some centres.

Scrotal pain: Mild to moderate discomfort is expected for 1–5 days. Severe or persistent pain (>1 week) should prompt review to exclude haematoma or epididymitis.

Epididymal fibrosis with repeated aspirations: Multiple PESA procedures can cause scarring of the epididymis, progressively reducing the retrievable sperm pool. Cryopreservation of adequate sperm at the first successful retrieval significantly reduces the need for repeated aspiration.

Sperm quality considerations: Epididymal sperm (PESA or MESA) have higher DNA fragmentation rates than ejaculated sperm in some studies, though the clinical significance for ICSI outcomes is modest and most studies show equivalent fertilisation and pregnancy rates. Testicular sperm in some analyses show lower DNA fragmentation than epididymal sperm.

Genetic transmission: In CBAVD-associated PESA, CFTR mutations carried by the father will be present in the sperm and may be transmitted to offspring. Pre-implantation genetic testing (PGT) is available if both partners carry CFTR mutations and wish to avoid cystic fibrosis in their children.

Recovery from PESA is straightforward and rapid, given the absence of a surgical incision. The primary follow-up focus is on the outcome of the synchronised IVF/ICSI cycle.

Immediate post-procedure care (day of procedure):

• Scrotal support (snug-fitting underwear) worn continuously for 48–72 hours
• Ice pack applied intermittently to the scrotum for the first 4–6 hours to reduce swelling
• Oral analgesia: paracetamol and ibuprofen for 2–3 days as needed
• Avoid strenuous physical activity and sexual intercourse for 5–7 days
• Return to driving and light work same day or the next day

Review of the procedure:

• If PESA is performed on the same day as egg collection (synchronised cycle), sperm are immediately prepared by the embryology laboratory for same-day ICSI
• If PESA is performed as a stand-alone 'banking' procedure prior to the IVF cycle, retrieved sperm are assessed, processed, and cryopreserved within 2–4 hours
• The embryologist reports on sperm count, motility, morphology, and viability of the retrieved sample

IVF/ICSI cycle outcomes:

• Fertilisation results available 16–18 hours after ICSI
• Embryo development monitored over 3–5 days; blastocyst culture increasingly performed to day 5–6
• Fresh embryo transfer or freeze-all strategy with frozen embryo transfer in a subsequent cycle
• Pregnancy test (serum beta-hCG) 14 days after embryo transfer
• Ultrasound confirmation of pregnancy at 6–7 weeks gestation

Long-term andrological follow-up:

• Annual semen analysis not applicable in azoospermic patients
• Men with CBAVD should be referred for genetic counselling given implications for children
• If fertility attempts are ongoing after 2–3 failed IVF cycles, reassessment of sperm retrieval strategy (escalation to MESA, TESE) and female factor workup is advisable

PESA costs must be considered in the context of the full IVF/ICSI treatment cycle, of which sperm retrieval is one component. The total cost of treatment depends significantly on whether sperm can be cryopreserved for multiple cycles from a single retrieval.

PESA procedure cost alone (not including IVF cycle):

• India: USD 300 – 800
• Thailand: USD 800 – 1,800
• Turkey: USD 600 – 1,500
• Malaysia: USD 800 – 1,500
• Singapore: USD 1,500 – 3,500
• United Kingdom: GBP 800 – 2,000
• United States: USD 1,500 – 5,000

Full IVF/ICSI cycle cost (including PESA, monitoring, egg collection, laboratory, and embryo transfer):

• India: USD 2,500 – 5,500 per cycle
• Thailand: USD 5,000 – 9,000 per cycle
• Turkey: USD 3,500 – 7,000 per cycle
• Singapore: USD 10,000 – 18,000 per cycle
• United Kingdom: GBP 5,000 – 8,000 per cycle
• United States: USD 15,000 – 30,000 per cycle

Additional cost factors to consider:

• CFTR genetic testing (both partners): USD 300 – 800
• Sperm cryopreservation and annual storage: USD 300 – 600 for freezing; USD 200 – 400 per year storage
• Escalation to MESA if PESA fails: Adds USD 1,500 – 5,000
• Pre-implantation genetic testing (PGT) of embryos: USD 3,000 – 7,000 additional per cycle — recommended if both partners carry CFTR mutations
• Medications (ovarian stimulation for partner): USD 1,000 – 4,000 depending on protocol and country
• Number of IVF cycles required: Most couples require 2–3 cycles for a live birth; cumulative costs multiply accordingly

For men with obstructive azoospermia, PESA is the simplest first-line option, but several alternatives exist at various levels of invasiveness and cost.

MESA (Microsurgical Epididymal Sperm Aspiration): Open microsurgical access to the epididymis through a scrotal incision, using an operating microscope. Retrieves substantially higher numbers of sperm than PESA — often sufficient for 10–20 ICSI cycles from a single procedure. Preferred when a large sperm bank is desired, when PESA has previously failed, or when microsurgical expertise is available at the time of egg collection. Requires general or spinal anaesthesia; recovery 7–10 days.

TESA (Testicular Sperm Aspiration): Percutaneous needle biopsy of the testis. Used when PESA fails or as a first-line alternative. Suitable for both obstructive and some non-obstructive cases. Lower sperm yield than PESA in obstructive cases but avoids repeated epididymal aspiration and potential fibrosis.

TESE (Testicular Sperm Extraction): Open testicular biopsy; multiple small biopsies taken from different areas of the testis. Used for non-obstructive azoospermia where sperm production is impaired. Not usually required in CBAVD or vasectomy-related OA where spermatogenesis is normal.

microTESE (Microsurgical Testicular Sperm Extraction): Gold standard for non-obstructive azoospermia. Operating microscope identifies the most likely sperm-bearing tubules. Success rate 40–60% in NOA vs. 15–20% for conventional TESE. Not indicated when obstructive azoospermia is confirmed.

Vasectomy reversal (vasovasostomy / vasoepididymostomy): Microsurgical restoration of the vas deferens patency. Allows natural conception without IVF. Success depends strongly on the time elapsed since vasectomy: pregnancy rates of 50–75% at <5 years post-vasectomy; 30–40% at >15 years. Cost-effective if multiple children are desired or partner is young with good ovarian reserve. Requires specialist microsurgical skills.

Donor sperm (donor insemination or donor sperm ICSI): An alternative to male partner sperm retrieval when all retrieval techniques fail, when genetic risks preclude using partner sperm, or when the couple chooses this option. Eliminates the need for sperm retrieval procedures entirely.