Testicular sperm aspiration (TESA) is a minimally invasive surgical sperm retrieval technique used for selected men with azoospermia. It is a key tool in the andrologist’s armamentarium, particularly for obstructive azoospermia, and is well-supported in the peer-reviewed literature as an effective first-line option in many clinical scenarios.
What Is TESA?
TESA involves inserting a fine needle through the scrotal skin into the testis and aspirating a small amount of testicular tissue and tubular fluid. The aspirate is then examined by the embryology laboratory to identify sperm, which are used for intracytoplasmic sperm injection (ICSI) during IVF or cryopreserved for future use.
When Is TESA Indicated?
- Obstructive azoospermia: The ideal indication, where sperm production is normal but a blockage prevents ejaculation of sperm (e.g., post-vasectomy, CBAVD, post-infectious obstruction)
- Ejaculatory dysfunction: Failed retrograde ejaculation management, anejaculation following spinal injury
- Severe oligospermia or cryptozoospermia: When ejaculated sperm are unreliable or of very poor quality
- Failed ejaculation on the day of ICSI as a backup retrieval option
TESA is generally not considered the first choice for non-obstructive azoospermia, where microdissection TESE has demonstrated superior sperm retrieval rates (Bernie et al., Fertility and Sterility 2015; Donoso, Tournaye, Devroey, Human Reproduction Update 2007).
How Is TESA Performed?
The procedure is carried out under local anaesthesia with or without sedation and typically takes 15–30 minutes:
- The scrotal skin is cleaned and local anaesthetic is infiltrated, including a spermatic cord block.
- A fine-gauge needle (commonly 18–21G) attached to a syringe is introduced into the testis.
- Negative pressure is applied, and tubular fragments are aspirated from several areas of the testis.
- The aspirate is handed to the embryologist, who processes and examines it immediately for sperm.
- If sperm are identified, they are used for ICSI or frozen for later use.
Outcomes in the Literature
- Obstructive azoospermia: Sperm retrieval rates consistently exceed 90% in published series, making TESA an excellent choice for these men.
- Non-obstructive azoospermia: Sperm retrieval rates are substantially lower (typically 10–30%), and randomised comparisons reported in Human Reproduction Update and Fertility and Sterility favour micro-TESE.
- ICSI outcomes: Fertilisation, implantation, and live birth rates with TESA-retrieved sperm in obstructive azoospermia are comparable to those with ejaculated sperm and with epididymal sperm retrieval techniques (Esteves SC, Asian Journal of Andrology).
Advantages of TESA
- Minimally invasive – no scrotal incision
- Short procedure time
- Performed under local anaesthesia
- Quick recovery, usually within 24–48 hours
- Can be repeated if needed
- Cost-effective compared with open microsurgical procedures
Limitations
- Lower sperm retrieval rates in non-obstructive azoospermia compared with micro-TESE
- Risk of focal haematoma or transient discomfort
- Not suitable when large volumes of tissue are required for retrieval or histological assessment
TESA vs. PESA vs. Micro-TESE
PESA (percutaneous epididymal sperm aspiration) targets sperm from the epididymis and is suitable for obstructive azoospermia. TESA samples sperm directly from the testis and is useful when PESA fails or in select non-obstructive cases. Micro-TESE is the gold standard for non-obstructive azoospermia, delivering higher retrieval rates at the cost of being a more complex procedure. Selection is individualised based on cause, prior history, and imaging.
TESA is a valuable, minimally invasive option for surgical sperm retrieval in appropriately selected men. Combined with ICSI, it provides excellent pregnancy rates in obstructive azoospermia and serves as a versatile tool in a comprehensive male infertility programme.
References drawn from peer-reviewed literature including Donoso P, Tournaye H, Devroey P (Human Reproduction Update 2007); Esteves SC (Asian Journal of Andrology); Bernie AM et al., Fertility and Sterility 2015; Practice Committee of the American Society for Reproductive Medicine (Fertility and Sterility); and European Association of Urology male infertility guidelines.