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Male infertility can be a result of impaired sperm production or a blockage preventing ejaculation. Fertility specialists use the sperm retrieval methods of TESA (Testicular Sperm Aspiration) or TESE (Testicular Sperm Extraction) in such cases. TESE involves a surgical biopsy of the testis, while TESA uses a needle to extract fluid and tissue from the testis. Sperm is then retrieved from the tissue.

TESE is the second best way to collect sperm in men with obstructive azoospermia and the technique of choice for men with non-obstructive azoospermia. It can be performed in an operating room or office procedure room using a local anesthetic. We recommend mild sedation for patient comfort. Sperm harvested using TESE can be frozen and stored for later use. The amount of sperm obtained from the testicular tissue is not nearly as much as obtained with MESA. Testicular sperm do not freeze and thaw as well as epididymal sperm, and are harder to work with in the andrology laboratory.

TESA or testicular sperm aspiration is a needle biopsy of the testicle. It is an office procedure performed under local anesthesia. A small incision is made in the scrotal skin and a spring loaded needle is fired through the testicle. While it is possible to retrieve sperm using this technique, the amount is often low because the needle cuts a thin sliver of tissue. Many embryologists find this small amount of tissue difficult to work with and do not get enough sperm to freeze for future use. Several studies have demonstrated that TESE is superior to TESA in all regards. The potential for complications is higher with this technique than with TESE (open biopsy) for two important reasons.

TESA is a blind needle stick and bleeding can not be stopped when it is accidentally encountered. The needle is larger in diameter than the intratesticular artery and can sever the artery, potentially cutting off testicular blood supply. The testicle may shrink and die. It is because of these reasons that we rarely offer TESA to our patients. Open biopsy (TESE) is more effective and potentially safer than needle biopsy (TESA) and is our technique of choice for obtaining testicular sperm for men with non-obstructive azoospermia.

Patients who require TESE can be divided into two categories : -
  1. The first set of patients are those men whose epididymis is not accessible because of previous epididymal procedures or congenital efferent ductal obstruction in the testis. This group with an obstructed testicle represents the first set of patients in whom successful TESE was combined with ICSI, and in 1994 a 42% clinical pregnancy rate was reported. More recent reports have demonstrated that in these obstructed patients, testicular retrieval seldom yields unusable sperm.

  2. Patients with testicular biopsies demonstrating Sertoli-cell-only, maturation arrest, or severe hypospermatogenesis represent another group of patients in whom testicular sperm retrieval has been used. These patients, who until recently were felt to be untreatable, can now often be treated effectively with in vitro fertilization (IVF) and ICSI if areas of normal sperm production can be demonstrated in a testicular biopsy.

Men with non-obstructive azoospermia caused by germinal failure can now be treated successfully in many cases using testicular sperm extraction (TESE--a term which we coined in 1993) and ICSI. There is a threshold of quantitative sperm production in the deficient testis, below which no sperm will reach the ejaculate (azoospermia). This threshold phenomenon of spermatogenesis is the reason that many cases ofnon-obstructive azoospermia, sperm can often be extracted from testicular tissue of azoospermic men with germinal failure, and used successfully for ICSI. A prior diagnostic testicle biopsy analyzed quantitatively can often predict the likelihood of finding such sperm during a TESE-ICSI attempt.


We wished to examine the quantitative presence of spermatogenesis in different regions of the testis in azoospermic men, in order to develop a rational microsurgical strategy for the TESE procedure. The goal was to maximize the chances for retrieving sperm from such men, to minimize tissue loss and pain, and to preserve the chance for successful future procedures.

Materials and Methods

A prospective study involving quantitative histologic analysis of testicular tissue in azoospermic men undergoing sperm retrieval for ICSI, with microsurgical removal of large contiguous areas of testicular tissue, was initiated. Careful analysis of tubular fullness observed at microsurgery was compared to quantitative histology. There were three groups. One group with non-obstructive azoospermia caused by testicular failure underwent diagnostic testicle biopsy prior to a subsequent TESE-ICSI procedure. The diagnostic testicle biopsy was analyzed quantitatively and correlated with the results of subsequent attempts at ICSI. A second group of men with non-obstructive azoospermia underwent multiple testis biopsy samplings from different regions of the testis in a testicular mapping effort during TESE. A third group of men with non-obstructive azoospermia underwent removal of large contiguous strips of testicular tissue with microsurgical dissection and evaluation of tubular dilation.

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