microTESE vs TESA vs PESA: choosing the right sperm retrieval
PESA, TESA and microTESE all collect sperm directly from men who have none in the ejaculate. The right one depends on why there are no sperm, not on which sounds most advanced.
PESA, TESA and microTESE are three ways of collecting sperm directly from a man who has none in his ejaculate. They are not better and worse versions of the same operation. Each is designed for a different underlying problem, and the most important decision comes before anyone chooses a technique: is your azoospermia obstructive, where sperm are made normally but cannot get out, or non-obstructive, where the testicles are making very few? I perform all three, as well as the reconstructive operations that can make retrieval unnecessary, so this guide sets out how the choice is actually made.
| PESA | TESA | microTESE | |
|---|---|---|---|
| What it is | A fine needle passed through the scrotal skin into the epididymis | A fine needle passed through the scrotal skin into the testis | An operation in which the testis is opened and searched under an operating microscope |
| Anaesthetic | Usually local, sometimes with mild sedation | Usually local, sometimes with mild sedation | General, usually as a day case |
| Best suited to | Obstructive azoospermia, most often after a vasectomy | Obstructive azoospermia | Non-obstructive azoospermia |
| Chance of finding sperm | Close to 100% in obstructive azoospermia | Close to 100% in obstructive azoospermia | About 50% in non-obstructive azoospermia |
| Typical recovery | Swelling and discomfort for a few days | Swelling and discomfort for a few days | Discomfort and bruising for one to two weeks; no heavy lifting, cycling or sport for three to four weeks |
Why does the type of azoospermia decide the method?
Because each solves a different problem: a needle collects sperm that are made normally but blocked in, while microTESE searches for the few areas still producing sperm.
In obstructive azoospermia the testicles work normally and the blockage lies somewhere between the epididymis and the ejaculatory ducts — after a vasectomy, an infection or childhood scrotal or hernia surgery, or because the vas deferens never formed. Because there is no problem with production, sperm can be retrieved with relative ease, and a needle is usually enough.
In non-obstructive azoospermia the problem is production. It is patchy rather than uniformly absent: some tubules inside the testis are still making sperm while most are not. A needle passed blindly into the testis can easily miss those areas. Finding them needs a systematic search, which is what microTESE is for.
Telling the two apart is the job of the initial assessment — examination of testicular size and the vas deferens, hormone tests (FSH is the single most useful discriminator), genetic tests and, where needed, ultrasound. I explain this in more detail on the azoospermia page, and it sits within a full male infertility assessment of both partners.
In obstructive azoospermia it is also worth asking whether you need retrieval at all. A blockage can sometimes be bypassed — by vasectomy reversal, by joining the vas directly to the epididymis, or by opening a blocked ejaculatory duct through the urethra (TURED) — which restores sperm to the ejaculate and allows natural conception. Whether reconstruction or retrieval makes more sense depends on your partner’s age, how many children you hope to have and, after a vasectomy, how long ago it was. I compare the two in vasectomy reversal vs sperm retrieval.
Which is better, TESA or PESA?
Neither is better across the board. Both are needle techniques for obstructive azoospermia, and the right one depends on the site of the blockage and where sperm can be collected.
PESA (percutaneous epididymal sperm aspiration) draws fluid from the epididymis, the coiled tube that stores and transports sperm as they leave the testis. TESA (testicular sperm aspiration) draws tissue from the testis itself. Both are done through the skin with a needle and syringe, usually under local anaesthetic, sometimes with mild sedation, and the British Association of Urological Surgeons (BAUS) puts the chance of finding sperm in obstructive azoospermia close to 100%.
If sperm can be drawn from the epididymis, there is no need to go further. If the epididymis yields none — for example because it has been scarred by infection — the testis can be sampled instead, because in obstructive azoospermia production inside the testis is normal. In both cases the sperm obtained are used with ICSI.
What is the difference between TESA and microTESE?
TESA is a needle aspiration under local anaesthetic for men with normal sperm production; microTESE is a microsurgical operation under general anaesthetic for men with severely reduced production.
In microTESE a small incision is made in the scrotum and the testis is opened. Under an operating microscope at 20 to 25 times magnification, I examine the seminiferous tubules systematically. Tubules that contain developing sperm are wider and more opaque than empty ones, so sampling can be targeted at the tissue most likely to yield sperm. Each sample goes straight to an embryologist in theatre, who examines it while the operation continues, so the search can be extended — to the other testis if necessary — when early samples are empty.
Targeting matters for two reasons. It finds sperm in men in whom random sampling does not, and it removes far less tissue. Men with non-obstructive azoospermia often already have borderline testosterone levels, so preserving the tissue that makes it is important for long-term health, not just for this attempt. A needle in the testis offers neither advantage, which is why TESA is a technique for obstruction.
Where does conventional TESE fit?
Conventional TESE sits between the two: an open procedure through a small scrotal incision that takes several small biopsies from the testis at random, without a microscope-guided search.
It samples more tissue than a needle, which is why it is used for non-obstructive azoospermia, but it relies on chance to hit the productive areas. In comparative studies quoted by BAUS, microTESE was about one and a half times as successful as TESE at finding sperm in difficult cases, and BAUS describes microTESE as the best choice for non-obstructive azoospermia. Random biopsy also removes considerably more testicular tissue, which puts testosterone production at risk. Because microTESE is only available in selected centres, you may be offered conventional TESE instead; if so, it is reasonable to ask why microTESE is not.
In non-obstructive azoospermia, the first attempt matters most
Sperm retrieval in non-obstructive azoospermia is usually a one-chance operation. Each procedure removes tissue and leaves scarring, which makes a second attempt harder and its yield lower. Confirm the diagnosis, complete the genetic tests and settle on the technique before the first operation, not after it.
How successful is microTESE?
Across men with non-obstructive azoospermia, microTESE finds sperm in approximately half, according to BAUS. Your own chance depends on the cause, your hormone profile, testicular volume and genetic results, and may be higher or lower than that.
Genetic testing before surgery is essential, because certain Y chromosome microdeletions predict that no sperm will be found; knowing that in advance can spare you an operation that cannot succeed. Where hormone levels can be improved, a period of medical treatment beforehand is sometimes recommended. The microTESE page covers preparation in detail.
Finding sperm is also not the same as a pregnancy. Sperm retrieved from the testis are few in number and may be immature, so they can only be used with ICSI, in which a single sperm is injected into each egg. From that point the outcome depends heavily on your partner’s age and fertility, which is why I recommend that your partner is assessed in parallel. The possibility that no sperm are found, and what you would do next, should be discussed before the operation rather than in recovery.
Is PESA or TESA painful?
Both are usually done under local anaesthetic, sometimes with mild sedation, and afterwards BAUS advises expecting some swelling and discomfort for a few days.
Simple painkillers such as paracetamol or ibuprofen, a scrotal support or firm underwear, and an ice pack wrapped in a cloth rather than placed directly on the skin all help in the first few days. Mild bruising and swelling of the scrotum are common after any sperm retrieval, affecting between 1 in 2 and 1 in 10 men. If bruising, swelling or pain gets steadily worse day by day, contact the surgical team.
How painful is a microTESE?
The operation itself is not painful, because you are under a general anaesthetic; afterwards, expect discomfort, swelling and bruising for one to two weeks.
Because the testis is opened, microTESE is a bigger procedure than needle aspiration and recovery takes longer. Supportive underwear helps, and most men return to desk work within a few days to a week. Long-term pain is uncommon: BAUS puts chronic testicular pain after sperm retrieval at between 1 in 50 and 1 in 250 men.
How long is the recovery after each procedure?
Plan on a few days of soreness after needle aspiration and one to two weeks after microTESE. BAUS recommends five to seven days off work after sperm retrieval, longer if your job is physical.
Needle aspiration leaves only a puncture in the skin. TESE and microTESE need a small incision, closed with dissolvable stitches that normally disappear within two to three weeks. After any of the procedures, avoid sexual activity until your scrotum and testicles are comfortable, and avoid heavy lifting or strenuous exercise for the first few weeks. After microTESE specifically, I advise no heavy lifting, cycling or sport for around three to four weeks.
What happens to the sperm after retrieval?
Any sperm found are passed to an embryologist and either used fresh, on the day of your partner’s egg collection, or frozen and stored for ICSI later.
Before retrieval you will need blood tests for HIV, hepatitis B and hepatitis C, taken within three months of the procedure, so that any sperm found can be frozen, and you will sign consent forms covering freezing and storage. Both routes are valid. Freezing in advance means your partner does not go through ovarian stimulation before you know whether sperm exist, and it removes the pressure of synchronising two procedures on one day. Using sperm fresh avoids any loss during freezing and thawing. I agree the plan with your fertility unit, and whichever route you take, the sperm are used with ICSI rather than conventional IVF or insemination.
Which procedure is right for you?
If your tests show a blockage, a needle technique or a reconstruction is usually right; if they show a production problem, microTESE gives the best chance.
The decision rests on a confirmed diagnosis, not on a single semen result. If you have just been told there are no sperm in your sample, start with can a man with azoospermia father a child?, which covers causes, tests and every route to fatherhood. When you are ready to discuss your own results, you can book a consultation in person or by video; bring any previous semen analyses, hormone tests and genetic results with you. Costs are explained on the fees and insurance page.
Sources and further reading
Frequently asked
How much does surgical sperm retrieval cost privately?
There is no single figure, because the cost depends on which procedure you need, the type of anaesthetic, whether it is a day case, the hospital, and the embryology and freezing fees charged by the fertility unit. After consultation you receive a written quotation covering surgeon, anaesthetist and hospital fees. An initial consultation is £350 in person or £300 by video or telephone. If you are insured, check with your insurer before booking whether the procedure is covered.
Is surgical sperm retrieval available on the NHS?
It can be. The NHS lists surgical sperm extraction as an option for men with a blockage, men born without a vas deferens, and men who have had a vasectomy or a failed vasectomy reversal. However, NHS-funded fertility treatment varies across the UK, and eligibility criteria differ between areas. Your GP can advise on the funding policy where you live.
Can sperm be retrieved after a vasectomy many years ago, or after a failed reversal?
Yes. A vasectomy blocks the tube but does not stop the testis making sperm, so this is obstructive azoospermia, and BAUS puts the chance of finding sperm close to 100%. The NHS specifically lists a previous vasectomy or a failed reversal as reasons surgical extraction may be offered. The time since your vasectomy matters mainly when weighing a reversal against retrieval.
A needle biopsy elsewhere found no sperm. Is microTESE still worth considering?
It can be, if your azoospermia is non-obstructive. A blind needle samples a tiny area, and production in non-obstructive azoospermia is patchy, so an empty needle sample does not prove that the testis contains no sperm; a systematic search under the microscope can find sperm where random sampling did not. The caveat is that any previous procedure removes tissue and leaves scarring, which makes a later microTESE harder and its yield lower. I accept referrals of men in whom retrieval has already been attempted elsewhere, and I will give you a realistic estimate based on your own results.
Will I know on the day whether sperm were found?
Usually, yes. The NHS notes that you are told on the same day about the quality of the tissue or sperm collected. During microTESE the embryologist examines samples while the operation is still under way, which allows the search to continue, and to extend to the other testis if needed.
Is there anything I should do before the procedure?
Tell the team if you take a blood thinner such as warfarin, aspirin, clopidogrel, rivaroxaban or dabigatran, if you have an implanted device such as a pacemaker or joint replacement, or if you have had MRSA. Stopping smoking helps: BAUS notes that smoking can worsen male-factor infertility and makes complications after surgery more likely.
What are the alternatives if sperm cannot be retrieved?
BAUS lists donor insemination and adoption as the alternatives to surgical sperm retrieval, and choosing not to pursue treatment further is also a legitimate decision. These options deserve a proper conversation before any surgery, so that you and your partner have already thought about every outcome rather than facing the question for the first time in recovery.
Speak to my team
Appointments at The Shard and Canary Wharf are arranged by my PA, Jeanette Bush. Tell us briefly what the problem is and we will find the right clinic slot for you.