PESA (Percutaneous Epididymal Sperm Aspiration) — 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 with obstructive azoospermia — a condition in which sperm are produced normally in the testes but cannot reach the ejaculate due to a blockage or anatomical absence of the ductal system. The procedure is performed under local anaesthesia and does not require any surgical incision.

PESA is performed by inserting a 23-gauge (23G) butterfly needle transcutaneously through the scrotal skin into the epididymal head or body. Negative pressure is applied using an attached syringe, and fluid containing sperm is aspirated. The fluid is immediately assessed by an embryologist in an adjacent laboratory for the presence, motility, and quality of sperm. PESA typically takes 10–30 minutes and patients can return home the same day.

The key advantage of PESA over surgical alternatives such as MESA (Microsurgical Epididymal Sperm Aspiration) is its simplicity: no operating microscope, no surgical incision, and no specialist microsurgical training is required, making it widely available in reproductive medicine centres worldwide. Sperm retrieved by PESA are used exclusively for Intracytoplasmic Sperm Injection (ICSI) as part of an in vitro fertilisation (IVF) cycle, because the numbers recovered are small and motility is often reduced compared to ejaculated sperm.

• Outpatient procedure under local anaesthesia
• No surgical incision required (percutaneous = through the skin)
• 23G butterfly needle aspiration from epididymal head or body
• Success rate of 90–95% in confirmed obstructive azoospermia
• Sperm used with ICSI; not suitable for conventional IVF insemination
• Sperm can be banked (cryopreserved) for multiple ICSI cycles

PESA is recommended as a first-line sperm retrieval technique when obstructive azoospermia is confirmed and microsurgical epididymal sperm aspiration (MESA) or surgical correction (vasovasostomy) is not feasible or desired.

PESA is specifically indicated for men with obstructive azoospermia (OA), where the pathway from testes to ejaculate is physically blocked or absent while testicular sperm production (spermatogenesis) remains intact. Understanding the underlying cause is important for selecting the most appropriate retrieval and conception strategy.

Post-Vasectomy Obstructive Azoospermia
Vasectomy is the most common cause of obstructive azoospermia worldwide. Men who have undergone vasectomy and later seek fertility may opt for either vasectomy reversal (vasovasostomy or vasoepididymostomy) or sperm retrieval with ICSI. PESA is a highly effective sperm retrieval option for post-vasectomy patients, with sperm found in virtually all cases (90–98%) in recent series. The decision between reversal and PESA+ICSI is influenced by the interval since vasectomy (reversal patency rates decline significantly after >15 years), female partner age, female fertility, and cost comparison.

Congenital Bilateral Absence of the Vas Deferens (CBAVD)
CBAVD is a congenital anomaly in which the vas deferens fails to develop, resulting in azoospermia despite normal testicular function. It is caused by mutations in the CFTR gene (the cystic fibrosis transmembrane conductance regulator) in the majority of cases and is the genital manifestation of cystic fibrosis. Genetic counselling for both partners is mandatory before proceeding to PESA+ICSI in CBAVD, as offspring carry a significant risk of CBAVD or cystic fibrosis depending on partner carrier status.

Epididymal Obstruction from Infection or Trauma
Epididymo-orchitis (bacterial or chlamydial epididymal infection), scrotal trauma, or prior scrotal surgery can cause epididymal scarring and obstruction. PESA may be attempted in these cases but success rates are lower (70–85%) than in post-vasectomy or CBAVD obstructions due to potential damage to the epididymal tubules.

• Post-vasectomy azoospermia (most common indication)
• Congenital bilateral absence of the vas deferens (CBAVD)
• Post-infectious epididymal obstruction (chlamydia, gonorrhoea, tuberculosis)
• Prior scrotal or inguinal surgery causing inadvertent ductal injury
• Ejaculatory duct obstruction (less common; distal obstruction)

Selecting appropriate candidates for PESA requires a systematic evaluation combining clinical assessment, semen analysis, hormonal profiling, and scrotal ultrasound. This workup distinguishes obstructive from non-obstructive azoospermia, which have fundamentally different prognoses and treatment pathways.

Diagnostic Confirmation of Azoospermia:
Two semen analyses with centrifugation of the pellet are required to confirm azoospermia (no sperm found in the ejaculate). A single negative result is insufficient for diagnosis. Cryptozoospermia (rare sperm found only on centrifugation) may be managed differently.

Hormonal Profile — Distinguishing OA from NOA:
In obstructive azoospermia, follicle-stimulating hormone (FSH) and inhibin B levels are typically normal because spermatogenesis is intact. Elevated FSH (>7.6 IU/L) and/or low inhibin B suggest non-obstructive azoospermia (NOA) due to primary testicular failure, where PESA success rates are very low. Testosterone and LH should also be measured to exclude hypogonadotrophic hypogonadism as a treatable cause.

Testicular Volume:
Normal or near-normal testicular volume (each testis ≥12 mL by orchidometer or ultrasound) supports the diagnosis of OA and predicts successful sperm retrieval. Small testes (<6 mL) suggest NOA and significantly reduce the likelihood of finding sperm at PESA.

Scrotal Ultrasound:
High-resolution scrotal ultrasound (10–15 MHz probe) identifies the presence and dilatation of epididymal tubules (dilated tubules in OA), confirms testicular echotexture (normal in OA), and locates the optimal aspiration site. Absence of the vas deferens on ultrasound suggests CBAVD.

Partner Evaluation:
Female partner fertility must be fully evaluated before PESA, as ICSI outcomes depend on oocyte quality and ovarian reserve. Advanced female age or reduced ovarian reserve affects IVF cycle success independently of sperm quality.

Genetic Counselling:
Men with CBAVD and their partners must undergo CFTR mutation screening before proceeding. Men with non-obstructive azoospermia should have karyotype and Y-chromosome microdeletion analysis.

PESA is performed as an outpatient procedure in a dedicated andrology or reproductive surgery unit. The technique is straightforward when performed by an experienced urologist or reproductive surgeon.

Anaesthesia:
The procedure is typically performed under local anaesthesia using a cord block (injection of lidocaine around the spermatic cord at the external inguinal ring) supplemented by subcutaneous scrotal infiltration. Oral anxiolytics (e.g., diazepam 5 mg) or conscious sedation may be offered in anxious patients. General anaesthesia is rarely required.

Step-by-Step Procedure:

• The scrotum is cleaned with antiseptic solution and the epididymis is fixed between the thumb and forefinger.
• A 23G butterfly needle (connected via tubing to a 20 mL syringe pre-loaded with culture medium) is inserted percutaneously into the epididymal head (caput) or body (corpus).
• Gentle negative pressure is applied by pulling back the syringe plunger while the needle is slowly advanced and rotated.
• The aspirated fluid (0.1–0.5 mL) is immediately passed to the embryology laboratory for microscopic evaluation.
• If no sperm are found, the needle is repositioned to a different site within the epididymis. Up to 3–4 punctures per epididymis may be made.
• If bilateral PESA is planned, the contralateral epididymis is sampled after the first side.

Sperm Banking (Cryopreservation):
Any sperm retrieved in excess of those required for the immediate IVF-ICSI cycle are cryopreserved in liquid nitrogen for future use. Cryopreservation reduces the need for repeated PESA procedures for subsequent IVF attempts and allows the partner to proceed with ovarian stimulation without scheduling pressures. Survival rates of PESA-retrieved sperm after freezing and thawing are 50–70% for motile sperm.

Fresh vs Frozen Sperm for ICSI:
Fresh PESA sperm generally yield slightly higher fertilisation rates than frozen-thawed sperm. However, a "freeze-all" strategy using cryopreserved PESA sperm is increasingly preferred because it allows optimisation of endometrial preparation and avoids synchronisation difficulties between sperm retrieval and oocyte collection.

PESA offers several significant advantages in the management of male obstructive azoospermia and has established itself as a first-choice sperm retrieval technique in many reproductive medicine programmes:

High Sperm Retrieval Rate in Obstructive Azoospermia:
In men with confirmed obstructive azoospermia (OA), PESA achieves sperm retrieval in 90–95% of attempts in post-vasectomy patients and 85–95% in CBAVD patients. This reliably high success rate makes PESA a predictable and trustworthy procedure when appropriate patient selection is applied.

Minimal Invasiveness:
Because PESA is performed through the scrotal skin without any incision, it avoids the bleeding, wound healing, and infection risks associated with open surgical procedures. Patients experience minimal discomfort (scrotal bruising and mild tenderness for 2–3 days), recover quickly, and can resume normal activities within 24–48 hours.

No Specialist Microsurgical Equipment Required:
Unlike MESA (Microsurgical Epididymal Sperm Aspiration), PESA does not require an operating microscope or microsurgical training. This makes it far more widely accessible in reproductive medicine centres globally and significantly reduces procedural cost.

Allows Sperm Banking:
Excess sperm can be cryopreserved, providing a sperm "bank" for multiple ICSI cycles without further retrieval procedures. A successful single PESA session with adequate banking can support 3–5 IVF-ICSI attempts.

Compatibility with ICSI:
PESA sperm achieve fertilisation rates of 60–75% per oocyte injected with ICSI, and clinical pregnancy rates per transfer are comparable to those achieved with ejaculated sperm in couples with matched female age and ovarian reserve.

• Outpatient, day-case procedure with rapid return to normal activities
• 90–95% sperm retrieval success rate in obstructive azoospermia
• Repeatable if first attempt yields insufficient sperm for banking
• Cost-effective compared to MESA or MicroTESE
• Widely available in IVF centres globally

PESA is a safe procedure with a low overall complication rate. However, patients should be informed of the following potential adverse events before proceeding:

Failure to Retrieve Sperm (Procedure Failure):
In approximately 5–10% of cases in obstructive azoospermia (and significantly more in suspected but unconfirmed obstruction), PESA fails to yield viable sperm. This may be due to incomplete obstruction, epididymal tubule damage from prior infection, or misclassification of non-obstructive azoospermia. In these cases, escalation to open surgical MESA or testicular sperm extraction (TESE/MicroTESE) is required, resulting in additional cost, anaesthesia exposure, and delay.

Haematoma:
Scrotal haematoma (blood collection in the scrotum) is the most common complication, occurring in 1–5% of cases. Most haematomas are small and resolve spontaneously; rarely, surgical drainage is required.

Infection:
Epididymo-orchitis (epididymal or testicular infection) following PESA is rare (<1%) when strict aseptic technique is used. Prophylactic antibiotics (e.g., single-dose oral ciprofloxacin or co-amoxiclav) are administered in some centres, particularly in patients with prior genital infection history.

Epididymal Damage:
Repeated PESA attempts may cause scarring within the epididymal tubules, potentially worsening obstruction. This is a theoretical concern with multiple punctures at the same session or repeated PESA procedures across multiple cycles. For patients requiring multiple IVF cycles, cryopreservation of sperm from the first retrieval session minimises the need for repeated PESA.

Pain:
Mild to moderate scrotal discomfort is expected for 2–5 days after PESA and is managed with simple oral analgesia (paracetamol, ibuprofen). Severe or prolonged pain (>7 days) should prompt clinical review to exclude haematoma or infection.

Genetic Transmission Risks (CBAVD):
Children conceived from PESA+ICSI in CBAVD fathers are at significant risk of inheriting CFTR mutations. Carrier testing of the female partner and pre-implantation genetic testing (PGT-M) should be discussed as part of the consent process.

PESA does not exist in isolation — it is performed as part of a coordinated IVF-ICSI treatment programme. Follow-up and next steps involve both the male and female partners and the IVF team.

Immediate Post-Procedure Care (Day 0–3):
Patients are discharged after a 1–2 hour observation period. Scrotal support (fitted underwear or jockstrap) is worn for 48–72 hours to minimise swelling. Ice packs applied for 20 minutes hourly on the day of the procedure reduce bruising. Patients should avoid strenuous activity, heavy lifting, and sexual intercourse for 5–7 days. Oral analgesia (paracetamol 1 g four times daily) is prescribed for 3–5 days.

Sperm Assessment Reporting:
The embryology laboratory provides a written report detailing sperm concentration found in the aspirate, percentage motility, morphology where assessable, and the number of vials cryopreserved. This report guides the IVF team in planning the number and timing of ICSI cycles.

Integration with Female Partner's IVF Cycle:
If fresh PESA sperm are used, the retrieval must be coordinated with the female partner's oocyte collection, typically occurring on the same day or the morning of egg retrieval. If cryopreserved sperm are used (freeze-all strategy), the female partner can undergo ovarian stimulation and oocyte retrieval independently, with embryo transfer in a subsequent frozen embryo transfer (FET) cycle.

• Scrotal review at 2–4 weeks if haematoma or pain persists
• IVF team meeting after PESA report to plan ICSI cycle timing
• Genetic counselling review (CBAVD patients) before embryo transfer
• Hormonal review if PESA failed to retrieve sperm (FSH, inhibin B repeat, consider testicular biopsy)
• Psychological support for both partners throughout the IVF process

Couples should be counselled that multiple IVF-ICSI cycles may be needed to achieve a live birth, and that cumulative live birth rates across cycles are substantially higher than single-cycle rates.

PESA is one of the most cost-effective sperm retrieval procedures available. However, the overall cost of achieving a live birth involves the combined cost of PESA plus the IVF-ICSI cycle, and potentially multiple cycles.

PESA Procedure Cost (2025–2026 estimates):

• United Kingdom (private): GBP 800–1,500 per retrieval session, typically including local anaesthesia and embryology assessment. NHS funding for IVF including sperm retrieval depends on clinical eligibility criteria and CCG/ICB policy.
• United States: USD 1,000–3,000 per PESA session (excluding associated IVF costs). Fertility treatment coverage under insurance plans varies; some states mandate coverage.
• India: INR 15,000–40,000 per PESA session at accredited fertility centres. India is a major destination for affordable IVF treatment including sperm retrieval procedures.
• Thailand and Southeast Asia: USD 500–1,200 per PESA session at international fertility centres.

Cryopreservation Storage Costs:
Annual cryostorage fees for banked sperm range from GBP 150–350 (UK) or USD 300–600 (US) per year. Most centres store for up to 10 years under human fertilisation and embryology regulations, with potential for extension upon application.

PESA vs Alternatives — Cost Comparison:

• PESA: USD 1,000–3,000 — lowest cost, outpatient, local anaesthesia
• MESA: USD 3,000–7,000 — requires operating microscope and microsurgical expertise, higher sperm yield
• TESA: USD 1,000–2,500 — similar cost to PESA; testicular source, fewer sperm
• MicroTESE: USD 5,000–15,000 — highest cost, general anaesthesia, reserved for NOA

For most patients with obstructive azoospermia, PESA represents the best value proposition, combining a high retrieval success rate with the lowest procedural cost and least patient discomfort.

Several alternative sperm retrieval and surgical correction techniques are available, each with specific indications, advantages, and limitations:

MESA (Microsurgical Epididymal Sperm Aspiration)
MESA is performed under general anaesthesia using an operating microscope. A small scrotal incision is made, and the epididymis is exposed. Under microscopic vision, an epididymal tubule is incised and fluid is directly aspirated. MESA yields substantially higher sperm numbers and better motility than PESA (enabling cryopreservation of more vials), but requires microsurgical expertise and a full operating theatre setup. It is preferred when extensive banking is required or when PESA has previously failed.

TESA (Testicular Sperm Aspiration)
TESA uses a needle to aspirate sperm directly from the testicular parenchyma rather than the epididymis. It is used in patients with PESA failure in OA, or as a first-line retrieval in some NOA cases. Sperm numbers and motility are typically lower than epididymal sources and ICSI fertilisation rates may be slightly reduced.

MicroTESE (Microsurgical Testicular Sperm Extraction)
The gold standard for non-obstructive azoospermia (NOA), MicroTESE uses an operating microscope to identify and selectively excise dilated seminiferous tubules within the testis that are most likely to contain focal spermatogenesis. It achieves sperm retrieval in 40–60% of NOA patients and is not indicated in obstructive cases where PESA is more appropriate and less invasive.

Vasectomy Reversal (Vasovasostomy / Vasoepididymostomy)
For post-vasectomy patients, surgical reversal aims to restore natural fertility without IVF. Vasovasostomy achieves patency in 85–97% of cases when performed within 10 years of vasectomy, with natural pregnancy rates of 55–75%. Beyond 15 years, vasoepididymostomy (anastomosis to the epididymis) may be needed and success rates decline. The choice between reversal and PESA+ICSI depends on vasectomy interval, female age, and patient preference.

Electroejaculation and Vibratory Stimulation
For azoospermia caused by spinal cord injury or retrograde ejaculation, penile vibratory stimulation or rectal electroejaculation under anaesthesia may produce ejaculated sperm for ICSI without the need for invasive retrieval procedures.