The reason for sperm extraction, its benefits and harms, and how the process is performed

Sperm retrieval has become one of the most important medical solutions for men facing fertility issues, especially when sperm count in the semen is extremely low or completely absent. This procedure can be performed using different techniques, including needle aspiration or microscopic surgery, with the primary goal of extracting sperm for use in Intracytoplasmic Sperm Injection (ICSI) to help couples achieve their dream of parenthood.In this article, we will cover everything you need to know about sper retrieval—how it is performed, when it is the best option, and its success rates—so you have all the essential information if you're considering this procedure.

What is a Testicular Biopsy Procedure?
A testicular biopsy is a procedure performed to extract sperm directly from testicular tissue. This is usually done in cases where sperm count in the semen is extremely low, or when there are issues with sperm shape, size, or movement, affecting its ability to fertilize an egg and achieve pregnancy.
After retrieving sperm through a microscopic biopsy, it is preserved until the intracytoplasmic sperm injection (ICSI) procedure is performed following egg retrieval from the wife.

How long does the procedure take?
If sperm is found during the detailed examination, it is extracted and frozen for future use in assisted reproduction techniques such as ICSI. The entire procedure takes approximately one hour.

Is sperm always found in the biopsy?
No, although the chances of finding sperm in a testicular biopsy are high, it is not guaranteed 100%.

When do biopsy results become available?
The results of sperm extraction, meaning whether sperm was found or not, are available on the same day of the procedure. However, the histopathology report (tissue examination results) is usually ready one week after the procedure.

What do abnormal biopsy results mean?
Abnormal results may indicate an issue with sperm function or hormone levels. In some cases, the biopsy can help determine the underlying cause of the problem.

Why might sperm be present in the testicles but absent in semen?
In some cases, sperm develop normally in the testicles, but a semen analysis shows no sperm or a very low count. This could be due to a blockage in the ducts that transport sperm from the testicles to the urethra. In certain cases, this blockage can be surgically corrected.

What Are the Potential Complications of a Testicular Biopsy?
There are no major risks associated with a testicular biopsy, but in some cases, swelling of the testicle or scrotum may occur after the procedure. This swelling usually lasts for a few days and gradually subsides, disappearing completely within a week.
A testicular biopsy does not affect future fertility, sexual ability, or hormone levels, provided it is performed correctly.
If the procedure is done under general anesthesia, there is a very slight risk of complications related to anesthesia.

What Are the Goals of Microdissection Testicular Sperm Extraction (Micro-TESE)?

To obtain the best possible quality of sperm.
To retrieve a sufficient number of sperm for fertilization.
To minimize potential damage to reproductive organs during the procedure.

Is Micro-TESE a Safe Procedure?

Yes, when performed by a skilled specialist, microdissection testicular sperm extraction (Micro-TESE) is a very safe procedure. It helps men suffering from non-obstructive azoospermia (NOA) achieve biological parenthood.
However, studies show that only about 17.9% of men with NOA are able to become biological fathers after undergoing this procedure.

Benefits of Testicular Sperm Extraction (TESE)

Testicular sperm extraction (TESE) offers several benefits, particularly for couples dealing with male infertility issues. Here are some key advantages:

Treatment for Azoospermia (Absence of Sperm in Semen)
TESE provides a practical solution for men with azoospermia, a condition in which sperm is completely absent in the semen. The procedure allows direct sperm retrieval from the testes, enabling biological fatherhood.
Suitable for Various Cases
TESE is effective for both obstructive azoospermia (where a blockage prevents sperm from reaching the semen) and non-obstructive azoospermia (where the testicles have difficulty producing sperm). This makes it a viable option for many men struggling with infertility.
Advanced Micro-TESE Technique
The advanced version of TESE, known as Micro-TESE, significantly enhances the chances of finding sperm. Using a surgical microscope, the surgeon can precisely locate areas in the testicular tissue most likely to contain sperm, increasing the success rate of sperm retrieval.
Use of Retrieved Sperm in Assisted Reproductive Techniques
Sperm extracted via TESE can be used in various assisted reproduction techniques, such as:
- In vitro fertilization (IVF)
- Intracytoplasmic sperm injection (ICSI)
  This improves the chances of conception for couples trying to have children.
Opportunity for Biological Fatherhood
This procedure provides hope for men who previously believed they could never have biological children, offering significant psychological and emotional benefits for them and their partners.
Sperm Freezing for Future Use
The retrieved sperm can be frozen and stored for future use. This is particularly beneficial for men undergoing medical treatments that may affect their fertility, such as chemotherapy or radiation therapy.

However, the success of the procedure varies from person to person. Consulting a specialist and undergoing a thorough evaluation is crucial to determine whether TESE is the right solution.

Reasons for Performing a Testicular Biopsy

There are several reasons why a doctor may recommend a testicular biopsy, including:

When a man is undergoing assisted reproductive techniques, such as IVF (in vitro fertilization) or ICSI (intracytoplasmic sperm injection).
In cases of azoospermia, where no sperm are present in the semen.
To determine the cause of male infertility.
When semen analysis shows a very low sperm count.
If there is a blockage in the sperm ducts that transport sperm.
If there is a defect in the sperm-producing cells.
In some cases, a testicular biopsy is performed to examine testicular tumors.

Success Rate of Micro-TESE (Microscopic Testicular Sperm Extraction)

Using Micro-TESE, the success rate of retrieving sperm is around 63%, compared to 20-45% with traditional extraction methods.

Success Rate of Testicular Biopsy Surgery

The success rate of the procedure depends on several factors, including:

The overall health condition of the patient.
The experience and skill of the surgeon.
The number of previous procedures performed.

Detailed Success Rates:

First-time procedure: Approximately 56% success rate.
Second or third procedure: Success rate decreases to 51%.
Fourth or more procedures: Success rate drops significantly to 23%.

How Many Times Can a Testicular Biopsy Be Performed?

A testicular biopsy can be performed multiple times, depending on the individual case. However, doctors generally try to limit the number of procedures to avoid potential complications.

When Is Micro-TESE Recommended?

After diagnosing the cause of azoospermia or sperm duct blockage, the doctor decides whether Micro-TESE is the appropriate solution. This decision is based on:

Physical examination
Hormonal tests
Ultrasound imaging of the sperm ducts

Conditions Requiring Micro-TESE:

1. Spermatogenic Arrest

Sperm production starts but stops at an early stage, preventing fertilization.

2. Hypo Spermatogenesis

All sperm production stages are present, but at a lower-than-normal rate, leading to a very low sperm count in semen.

3. Sertoli Cell-Only Syndrome

The sperm-producing cells are absent in the testicles, causing complete azoospermia.

4. Other Cases

A testicular biopsy may also reveal past testicular infections or the presence of abnormal cells, which may contribute to male infertility.

Is a Testicular Biopsy Painful?

In most cases, a testicular biopsy is performed under local or general anesthesia, so the patient does not feel any pain during the procedure.

However, after the procedure, mild pain or swelling may occur. To minimize discomfort and swelling, doctors recommend:

Applying cold compresses on the testicles for the first 24 hours after the procedure.
Avoiding sexual activity for at least two weeks.
Taking prescribed medications, such as blood thinners, as instructed by the doctor.
Keeping the wound clean and dry to prevent infections.

Types of Testicular Biopsy

The choice of technique depends on the patient’s medical condition, and the doctor determines the most suitable method.

Methods for Extracting Sperm from the Testicles:

PESA (Percutaneous Epididymal Sperm Aspiration)
- Sperm is aspirated from the epididymis using a fine needle.
- Suitable for obstructive azoospermia (blocked sperm ducts).
MESA (Microsurgical Epididymal Sperm Aspiration)
- Uses microsurgery to extract sperm from the epididymis.
- Allows the retrieval of sperm from a single tubule, improving the chances of obtaining healthy sperm.
TESA (Testicular Sperm Aspiration)
- Sperm is aspirated directly from the testicle using a fine needle.
- Often used for sperm production issues or blockages.
TESE (Testicular Sperm Extraction)
- Involves a small incision in the testicle to extract sperm.
- Suitable for cases where no sperm are found in semen.
Micro-TESE (Microscopic Testicular Sperm Extraction)
- The most advanced and precise sperm extraction technique.
- Uses a surgical microscope to locate tubules with the highest sperm production.
- Minimizes tissue damage and increases the chances of sperm retrieval.

Testicular Biopsy for Azoospermia (Absence of Sperm in Semen)

If no sperm are detected in a semen analysis, the doctor determines the most suitable sperm retrieval method based on the underlying cause:

Needle Aspiration Techniques (PESA – MESA – TESA):
- Used when sperm duct blockage is the cause of azoospermia.
- In cases of very weak sperm production, direct sperm extraction from the testicles improves the success rate of ICSI (Intracytoplasmic Sperm Injection).

Micro-TESE Technique
This is the best option for cases with sperm production issues, as it offers the highest success rate compared to other techniques.

TESE (Open Biopsy)
A surgical procedure where the testicle is opened to extract sperm.
Suitable for cases with blocked sperm ducts or sperm production problems.
Types of Sperm Retrieval Using Microsurgical Techniques
The choice of the appropriate technique depends on several factors, including:
✔️ Cause of infertility (whether due to blocked ducts or sperm production issues).
✔️ Patient's health condition and the presence of sperm in the testicle or epididymis.

1. Percutaneous Epididymal Sperm Aspiration (PESA)
Minimally invasive technique, where sperm is retrieved from the epididymis or testicle using a needle without surgical incision.
Performed under local anesthesia and involves:
Inserting a fine needle through the scrotal skin to reach the epididymis or testicle.
Examining the sample under a microscope to confirm the presence of healthy sperm.
The retrieved sperm can be used immediately for ICSI (Intracytoplasmic Sperm Injection) or frozen for future use.
2. Microsurgical Epididymal Sperm Aspiration (MESA)
Used when PESA fails and is mainly performed for blocked sperm ducts with normal sperm production.
Performed under general anesthesia and includes:
Making a small surgical incision in the scrotum and aspirating fluid from the epididymis.
Examining the fluid for the presence of viable sperm.
If no sperm are found, small tissue samples are taken from the testicle using a microsurgical approach.
Closing the incisions with dissolvable stitches.
The retrieved sperm is used for direct fertilization (ICSI) or frozen for later use.
3. Testicular Sperm Aspiration (TESA)
Used in cases of epididymal blockage or obstruction within the testicular ducts.
Procedure steps:
Local anesthesia is administered.
A fine needle is inserted into the testicle to aspirate fluid and tissue samples.
The sample is processed in an embryology lab to extract sperm.
The sperm is then used for ICSI (Intracytoplasmic Sperm Injection).

Preparation for the Procedure

✔ Shaving the hair in the scrotal area.
✔ Fasting from food and drinks for 6-8 hours before the procedure.
✔ Informing the doctor about any implanted medical devices (such as stents, heart valves, or pacemakers).
✔ Informing the doctor about any medications or supplements being taken, especially blood thinners like aspirin.
✔ Informing the doctor about any current or past MRSA infections.

Note: The success rate of each technique varies depending on the patient's condition and the cause of infertility. Therefore, consulting a doctor is essential to determine the best option.

Possible Risks of Testicular Biopsy

Although testicular biopsy is beneficial for procedures like ICSI (Intracytoplasmic Sperm Injection) and IVF (In Vitro Fertilization), there are potential side effects, especially if post-operative instructions are not followed properly. These risks include:

Severe pain that may not subside with regular painkillers.
Bleeding due to damage to small blood vessels in the testicle.
Hematoma (blood accumulation under the skin), leading to swelling and additional pain.
Fever, which may indicate an infection.
Swelling of the scrotum due to irritation or blood accumulation after the procedure.

Factors to Ensure the Best Results from a Testicular Biopsy

To increase the chances of finding sperm in the sample and improving ICSI outcomes, it is recommended to follow certain practices that enhance testicular health, including:

✔ Reducing excessive weight, as obesity can negatively impact sperm production and quality.
✔ Quitting smoking to avoid poor sperm motility and increased abnormalities.
✔ Treating underlying health conditions, such as varicocele. Surgery for varicocele is recommended, followed by a waiting period of 6-9 months before reassessing fertility.

The Relationship Between Testicular Sample Quality and ICSI Success Rate

The better the quality of sperm extracted from the biopsy, the higher the chances of ICSI success. The success rate depends on:

The number and quality of the retrieved sperm (motility and normal morphology).
The viability of the eggs retrieved from the wife.
The absence of uterine issues that may affect embryo implantation.

Testicular Biopsy Analysis

After extracting the sample, it is examined under a microscope to determine the cause of low or absent sperm count. Possible causes include:

Blockage of the seminal ducts, preventing sperm from reaching the semen.
Varicocele, which affects sperm production.
Smoking and alcohol consumption, leading to poor motility and increased abnormalities.
Hormonal imbalances, which hinder sperm production.
Previous surgeries, such as prostate surgeries or vasectomy.
Exposure to industrial chemicals, which may affect fertility.
Undescended testicles, which can interfere with sperm production.
Spermatocele, a fluid-filled cyst that may block sperm release.

Procedure After Extracting the Testicular Sample

Once the sample is retrieved, it undergoes a series of meticulous steps to ensure optimal analysis and results.

Initial Examination in the ICSI Laboratory

The sample is immediately placed in a special solution that helps activate and stimulate sperm movement.
It is examined under a microscope in the ICSI lab, which is connected to the operating room.
If sperm are found, they are preserved for either immediate use in ICSI or freezing for future procedures.

What Happens If No Sperm Are Found?

If no sperm are detected in the first 8 extracted samples, the following steps are taken:

An additional 8 tiny samples are taken from different areas of the same testicle, ensuring minimal impact on its size.
If sperm are found in a specific area, more tissue is taken from that spot to collect a sufficient amount for ICSI.
If no sperm are found in all extracted samples from the first testicle, the doctor closes it and proceeds to extract samples from the other testicle, repeating the same process.

Final Stage: Centrifugation & Tissue Analysis

If no sperm are found in both testicles, an advanced analysis stage is performed:

Using a Centrifuge Machine

All negative samples are placed in a centrifuge, which spins at high speeds to separate even a minimal number of sperm if present.
In some cases, a very small number of sperm can be found this way.

Testicular Tissue Analysis

If no sperm are detected even after centrifugation, a tissue sample is sent to a specialized lab for histological analysis.
This analysis helps determine:
- The structure of the testicular tissue.
- The degree of cellular abnormalities.
- The underlying cause of sperm production failure

Additional Procedures Before Completing the Operation

Before closing the testicle, the surgeon injects a special substance to prevent adhesions inside the scrotal tissue. This is done in case future surgeries are needed.

Success Rates of Testicular Sperm Extraction (TESE)

The success rates of TESE vary depending on several factors, including the cause of infertility, the technique used, the surgeon’s expertise, and the patient’s overall health.

Success Rates Based on Type of Azoospermia

Obstructive Azoospermia (OA)

High success rate (up to 90%), as the issue lies in blocked ducts rather than sperm production.
The testicles are typically healthy and produce normal sperm, making extraction easier.

Non-Obstructive Azoospermia (NOA)

Lower success rate (30% - 70%), depending on the extent of sperm production in the testicles.
Micro-TESE is used to increase the chances of finding sperm by identifying active areas under a microscope.
Genetic or hormonal issues may impact success rates.

Factors Affecting the Success of TESE

✅ Surgeon’s Expertise

The more experienced the surgeon, the higher the chances of retrieving viable sperm.
Micro-TESE provides better results compared to traditional techniques.

Patient’s Age & General Health

Younger patients have a higher probability of extracting healthy sperm.
Chronic diseases like diabetes or hormonal disorders may negatively impact success.

Preoperative Diagnostic Tests

Hormonal analysis (FSH, LH, testosterone) helps predict sperm retrieval success.
Ultrasound imaging of the testicles detects structural abnormalities.

TESE does not guarantee sperm retrieval in all cases, and success depends on each patient's unique condition.

Recovery Period After Testicular Biopsy

Returning Home

The patient can go home on the same day after the procedure but should get adequate rest.

Resuming Daily Activities

Return to work within a few days, depending on the job type.
Resume exercise and strenuous activities after 1-2 weeks.

Tips for a Fast Recovery

Avoid tight clothing to reduce sweating and friction.
Keep bandages and gauze in place to prevent infections.
Avoid heavy lifting or cycling for two weeks.
Keep the surgical area dry for a few days.
Do not take blood thinners (like aspirin) unless prescribed by the doctor.
Take antibiotics and painkillers as directed by the doctor.

Following these guidelines speeds up recovery and minimizes complications!

Specialty for Testicular Sperm Extraction

The appropriate medical specialties for sperm retrieval from the testicle are Andrology & Infertility or Urology & Reproductive Surgery.
These procedures are typically performed by a consultant in andrology (male fertility specialist) or a urologist specializing in male infertility.

If you are looking for a specialist, it is best to visit a fertility clinic or IVF center, as they have extensive experience in these procedures.

The appropriate medical specialty for sperm retrieval from the testicle is Andrology & Infertility or Urology & Reproductive Surgery.

Typically, this procedure is performed by a consultant in andrology (male fertility specialist) or a urologist specializing in male infertility.

If you are looking for a doctor, it is best to visit a specialized fertility center or IVF clinic, as they have extensive experience in these procedures.

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