TESE: what is testicular sperm extraction?

Conception sounds like a simple process: the sperm swims to an egg, gets inside, and creates a baby. But there are a surprising number of things that can go wrong during the journey. 

Sometimes there isn’t enough sperm released during ejaculation to fertilize an egg or sperm is blocked from being released. For that reason, there are special techniques healthcare providers can use to collect sperm directly from the source and use them to fertilize an egg. Enter TESE.  

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Called TESE for short, testicular sperm extraction is a procedure used to collect sperm directly from the testicles rather than from ejaculation. A healthcare provider or specialist (urologist) performs this procedure, sometimes right in their office. 

There are different types of TESE procedures, including (Ezeh, 1998; Flannigan, 2017):

• Conventional TESE (cTESE): During cTESE, a small incision is made in the skin of the scrotum. A sample is then collected from the testicle and is analyzed to identify and collect sperm.

• Microscopic TESE (microTESE): This method involves making an incision in the scrotum and using a microscope to look more closely at the tubes where sperm develop (seminiferous tubules). It’s a more complex process and is done in the operating room under general anesthesia. 

MicroTESE has a higher success rate than cTESE as more sperm can usually be retrieved (Bernie, 2015). Because of this, microTESE is often the first choice for sperm extraction procedures (Flannigan, 2017). 

Testicular extraction may be recommended for people with no sperm in their ejaculate. Called azoospermia, this condition is seen in up to 15% of men with infertility (Tsujimura, 2007). There are two types of azoospermia (Cocuzza, 2013):

• Obstructive azoospermia (OA): In this case, a blockage prevents sperm from leaving the testicles and into the penis for ejaculation. The blockage can be caused by a build-up of scar tissue, previous surgery, infection, or other injuries. TESE can bypass the blockage to collect sperm for artificial insemination procedures like in vitro fertilization (IVF) and ICSI (intracytoplasmic sperm injection). 

• Non-obstructive azoospermia (NOA): This is when testicles produce very little sperm or none at all. For some people, a few tubules in the testes still produce sperm, but it might not be enough to detect in a semen sample. TESE can be helpful for identifying which tubules are functioning so sperm can be retrieved directly from them and then used to fertilize an egg. 

TESE is sometimes used to help preserve fertility in people with certain medical conditions. For example, people with cancer may undergo TESE before receiving radiation or chemotherapy which may harm sperm production (Guo, 2018).

People with a genetic condition called Klinefelter syndrome often lose sperm cells during puberty. They may undergo TESE around the onset of puberty to preserve future fertility (Gies, 2016).   

TESE is also helpful for male-to-female transgender individuals. Hormones given during their transition may damage testicular tissue, so TESE can be done beforehand to preserve fertility (Liu, 2019). 

TESE is often a first-choice procedure, but others are available, depending on the situation. Some other options for sperm retrieval include (Esteves, 2011):

• TESA (testicular sperm aspiration): This procedure is similar to TESE, except there’s no open incision. During TESA, sperm are removed from the testicles using a needle. One downside to TESA is sometimes it doesn’t retrieve enough sperm and you need to have a TESE done afterward. 

• PESA (percutaneous epididymal sperm aspiration): In PESA, a needle is used to collect sperm from the small tube (epididymis) that sperm travel through for ejaculation. PESA can retrieve sperm unable to exit the testes because of a blockage, so it’s useful for obstructive azoospermia, but not for people with non-obstructive azoospermia.  

• MESA (microsurgical epididymal sperm aspiration): This procedure is also helpful for people with obstructive azoospermia. The MESA method collects sperm from the epididymis through an incision. Since there’s an open incision involved rather than just a needle, you might feel a little more discomfort after it’s done.

Conceiving may be challenging when you don’t have enough sperm in your ejaculate or if something is blocking their way out. 

Procedures like TESE may be able to help by collecting sperm right from the testicles. If you have questions about fertility, a good first step is speaking to a healthcare provider or fertility specialist for advice.  

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Current version

May 19, 2022

Written by

Gina Allegretti, MD

Fact checked by

Yael Cooperman, MD

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About the medical reviewer

Yael Cooperman, MD, Ro

Yael Cooperman is a physician and works as a Senior Manager, Medical Content & Education at Ro.