What is the testicular sperm extraction (TESE) procedure, including its indications, technique, postoperative care, and alternative options?

Testicular Sperm Extraction (TESE) Procedure

For men with non-obstructive azoospermia requiring surgical sperm retrieval, microdissection TESE (micro-TESE) is the preferred technique over conventional TESE, offering 1.5 times higher sperm retrieval rates with fewer complications. 1

What is TESE?

TESE is a surgical procedure to retrieve sperm directly from testicular tissue for use in assisted reproductive technology (specifically ICSI - intracytoplasmic sperm injection). Two main techniques exist:

Conventional TESE (cTESE)

• Involves random biopsies of testicular tissue
• Sperm retrieval rate: approximately 50% 2
• Higher complication rates (hematoma, fibrosis) 2
• Greater negative impact on postoperative testosterone levels 1

Microdissection TESE (micro-TESE)

• Uses operative microscopy to identify seminiferous tubules most likely to contain sperm
• Wide opening of tunica albuginea allows examination of multiple testicular regions
• Tissue oriented in centrifugal pattern parallel to intratesticular blood supply
• Minimizes inadvertent vascular damage 1
• Sperm retrieval rate: 1.5 times higher than conventional TESE 1
• Lower complication rates for hematoma and fibrosis 2
• Less impact on testosterone levels (though testosterone deficiency requiring replacement remains a risk) 1

Primary Indications

Non-Obstructive Azoospermia (NOA)

• Primary indication for TESE 3
• Includes: Klinefelter syndrome, post-chemotherapy, idiopathic NOA, AZFc microdeletions
• Micro-TESE particularly advantageous when testicular volume <12 mL 3

Obstructive Azoospermia (OA)

• TESE is an option when microsurgical reconstruction (vasovasostomy/epididymovasostomy) is not feasible or has failed 4
• Important caveat: Epididymal sperm retrieval should be avoided if future microsurgical reconstruction might be pursued due to risk of epididymal scarring 1
• Fertilization, pregnancy, and live birth rates are similar for epididymal vs. testicular sperm in obstructive cases 1

Emerging Indications (Non-Azoospermic Men)

• Elevated sperm DNA Fragmentation Index (DFI): Testicular sperm shows improved clinical pregnancy rates, live births, and reduced pregnancy loss compared to ejaculated sperm 1
• Cryptozoospermia
• Necrospermia
• Recurrent IVF failure with ejaculated sperm 5

Fertility Preservation

• Pre-gonadotoxic therapy: Sperm banking preferred, but TESE option if azoospermic 1
• Post-gonadotoxic therapy: Micro-TESE for persistent azoospermia (Strong Recommendation, Grade B) 1
• Testicular cancer (onco-TESE): Simultaneous radical orchiectomy and micro-TESE for azoospermic patients 6, 7, 8

Contraindications

Complete AZFa and AZFb microdeletions: Sperm retrieval likelihood is almost zero; TESE is contraindicated 2

Predictive Factors for Success

Favorable Factors

• Hypospermatogenesis pattern on testicular biopsy: Best predictor of successful sperm retrieval 2
• AZFc microdeletions (not AZFa/AZFb) 3

Unfavorable Factors

• Maturation arrest pattern 2
• Sertoli cell-only syndrome (SCOS) 2
• Complete AZFa/AZFb deletions 2

Inconsistent/Limited Predictive Value

• FSH, LH, inhibin B, AMH levels: Variable correlation, limited retrospective data 2
• Testicular volume: Inconsistent predictor 2

Pre-Operative Evaluation

Essential workup before TESE:

• Hormone status (FSH, LH, testosterone)
• Genetic testing: Karyotype and Y-chromosome microdeletion analysis
• Counsel on costs and possibility of unsuccessful sperm retrieval 3
• Do NOT perform testicular FNA mapping: No RCTs support its use; requires two procedures instead of one, delays treatment 2

Surgical Technique (Micro-TESE)

1. Wide opening of tunica albuginea
2. Systematic examination of multiple testicular regions under operative microscopy
3. Identification of larger, more opaque seminiferous tubules (higher likelihood of spermatogenesis)
4. Selective excision of promising tubules
5. Tissue oriented parallel to intratesticular blood supply to minimize devascularization 1

Key technical point: Multiple biopsies increase sperm retrieval success 2

Post-Operative Care and Monitoring

Immediate Complications (Rare)

• Bleeding/hematoma
• Infection
• Testicular atrophy 3

Long-Term Monitoring

Critical: Monitor for post-operative hypogonadism

• Both conventional TESE and micro-TESE can cause testosterone decline
• Micro-TESE has less impact than conventional TESE 1
• Many NOA patients have baseline testosterone deficiency 1
• Testosterone replacement may be required post-operatively 1
• Recovery of baseline testosterone at long-term follow-up observed in many cases 2

Alternative Options

Medical Optimization (Limited Evidence)

For NOA patients, may consider off-label pharmacologic manipulation before surgery:

• Selective estrogen receptor modulators (SERMs)
• Aromatase inhibitors (AIs)
• Gonadotropins (hCG)
• Caveat: Only subset of patients eligible based on hormonal profile; limited outcome data 1

Salvage Micro-TESE

• 46.5% success rate in patients with prior failed conventional TESE or testicular sperm aspiration 2
• Demonstrates superiority of micro-TESE technique

Donor Sperm

• Alternative if TESE unsuccessful or contraindicated

Collaboration Requirements

Essential multidisciplinary approach:

• Urologist/andrologist
• Reproductive endocrinologist
• Embryologist
• Human geneticist 3

Evidence Quality Note

The 2025 EAU guidelines acknowledge that current evidence is low quality with paucity of RCTs comparing conventional TESE and micro-TESE 2. Despite meta-analyses showing comparable sperm retrieval rates, all individual trials showed micro-TESE superiority, and complications are consistently lower with micro-TESE. The consensus expert opinion strongly favors micro-TESE as the optimum approach 2.