Sperm aspiration techniques explained

Thomas A. Masterson, MD
Assistant Professor in Urology, University of Miami – Miller School of Medicine

Male Factor

From this video you will find out:
  • Which sperm retrieval procedure is recommended?
  • What is the difference between Percutaneous Epididymal Sperm Aspiration (PESA) and Microepididymal Sperm Aspiration (MESA), when are they indicated?
  • What is Micro TESE/TESA?
  • TESA or TESE: Which Is Better for Sperm Extraction?
  • Who would benefit from TESA or Micro TESE?
  • Which technique is better in obstructive azoospermia (OA) versus non‐obstructive azoospermia (NOA)?

What are surgical sperm retrieval techniques and when are they indicated?

In this session, Dr Thomas A. Masterson, MD, Assistant Professor in Urology at the University of Miami and Bruce W Carter VA Medical Centre in Miami, Florida, has discussed sperm aspiration techniques such as PESA, MESA, TESE, TESA, MicroTESE.

Dr Masterson started by explaining the reason for retrieving sperm. It’s impossible to do the IVF process if you don’t have both an egg and sperm. Sperm retrievals are reserved for patients who are unable to supply a sperm sample. These situations include anejaculation (inability to provide a sample), obstructive azoospermia means that there’s no sperm in the ejaculate, also patients who have had a prior vasectomy and are now looking to have children, that’s a that’s an example of obstructive azoospermia. Another situation is non-obstructive azoospermia, in these instances, the patients are not making very much sperm, so there’s no blockage, it’s just the testicle is not producing sperm in large enough quantities to see it in the ejaculate.

Where do we find sperm? The easiest and usually the most common is in the ejaculate, and again the ejaculated sperm is what can be provided by the patient. This can either be collected through masturbation or other techniques. The second most common location for sperm would be the epididymis, which sits on top of the testicle, and this is where sperm is stored. It’s also the area where sperm gains motility. Sperm is developed in the testicle starting from the most immature to getting to a matured state. Each of these locations has sperm of different quality that can only be used for certain assisted reproductive techniques.

Sperm can be used for three main things outside natural conception. The first is intrauterine insemination or IUI which is the process where they take the sperm, concentrate it, and inject it into the uterus. Not all types of retrievals can be used for intrauterine insemination. The second type is in vitro fertilization (IVF), it’s where sperm and egg are put together in a dish and allowed to fertilize on their own. Only motile or moving sperm can be used for this technique. The last is intracytoplasmic sperm injection or ICSI, where you take a single sperm and inject it into an egg to fertilize.

Ejaculated sperm

Ejaculated sperm is probably the most common way that sperm is taken. This is what is used for semen analyses and what is the quality. The benefit of ejaculated sperm is that it is moving, so it’s easier for the embryologist to determine which sperm they’re going to use, it’s fully matured, and it also contains the lowest aneuploidy. As it moves to the reproductive tract, sperm that contains aneuploidy tends to die off and doesn’t make it to the ejaculate. The downside of ejaculated sperm is that this is the area with the highest DNA fragmentation, which happens as the sperm matures, and is exposed to things like reactive oxygen, species or the body’s own immune system. This can cause small damage to the DNA that’s in the sperm. Those sperm do make it into the ejaculate and can survive. How is ejaculated sperm obtained? The most common way is through masturbation, some patients use collection condoms, and for patients who have ejaculatory disorders, there’s penile vibratory stimulation (PVS) and electrical ejaculation (EEJ). Ejaculated sperm can be used usually for intrauterine insemination assuming we have large enough quantities, IVF or ICSI.

The rates of ejaculated sperm versus surgically retrieved sperm show that fertilization rates are higher with ejaculated sperm. However, looking at clinical pregnancy rates, the rates are similar.

Epididymal sperm

Epididymal sperm is moving, and it is fairly mature, and again motile sperm means it is alive, sperm that’s not moving is dead, especially in the ejaculate. Motile sperm that’s typically the sperm that is usually used in the techniques like ICSI. The drawback is that epididymis is where the sperm gains its motility. Depending on where the sperm is retrieved in the epididymis, the motility may be fairly low. There are two main ways that we get sperm from the epididymis. One is called a Percutaneous Epididymal Aspiration or PESA, the other is a Micro Epididymal Sperm Aspiration or MESA.

PESA is usually performed under local anesthesia, a needle is directed into the epididymis, and with light suction some of the fluid is taken that hopefully contains sperm. The benefit of this procedure is that it’s fairly quick, and it doesn’t require much coordination or use of a microscope. The downside is the yield of sperm that you get is low, it may require multiple attempts and the more times you stick the epididymis, the more scarring it may develop making future attempts more difficult.

MESA procedure is done under local or under general anaesthesia. The testicle is delivered through an incision and a microscope is used to look at the tubules directly and then a needle is placed into them to aspirate sperm. This generally has a higher yield of sperm and it is possible to get multiple vials that can be saved and used for future IVF cycles. The drawbacks are, that it does require general anaesthesia, potentially it’s more painful since larger incisions are made and it does require the use of an operating microscope.

Epididymal sperm, in rare cases, can be used for IUI but is usually used for IVF or ICSI. When comparing the epididymal sperm and fertilization rates versus testicular sperm, epidermal sperm is moving, it has a higher fertilization rate. There is a slightly higher clinical pregnancy rate, despite this, in this particular study, that difference was not statistically significant. There’s also a question of using fresh versus frozen sperm. Fresh sperm is used to fertilize the eggs on the same day as it is retrieved, in the frozen cycle, sperm will be frozen and then thawed when it is needed and used to do the fertilization. The difference in fertilization and clinical pregnancy rates are not substantially different between frozen and fresh sperm.

- Questions and Answers

Do you use ICSI as a standard procedure at your practice?

I will sort of little deflect, so in my practice, I deal mostly on the male side, so my goal is to try and get sperm, the most advanced sperm, meaning that has the highest quality to be used for whatever the patients are trying to do. In the United States, ICSI is becoming the standard for IVF, different offices have different protocols, but yes, I know that is not the case around the world.

How many times TESE or mTESE can be done in a patient?

It depends on the reason the patient is having it. For patients who are obstructed, we try to do one good procedure, and if there’s leftover sperm, freeze it for future use. I do have patients who don’t want to go under general anaesthesia or have reasons that they can’t, and I will do the TESE needle biopsy as many times as is needed. I’ve done as many as four for four different IVF cycles.

When it comes to the mTESE, I will do one if we find sperm, and if they have an unsuccessful IVF cycle and are looking to try and do another, I would consider doing a repeat mTESE. In patients where we do not find sperm on the first mTESE, I do not do a second mTESE.

What is the recommended treatment for sperm DNA fragmentation? 

With sperm DNA fragmentation, there can be multiple reasons why patients have it, and if you have an identifiable cause of it, we first try to treat that. There may be patients who come in with a high DNA fragmentation, and no one’s checked their semen for other causes such as infections or high white blood cell counts. If that’s the case, we try to treat the infection, try to treat the leukocytes or the white blood cells and then recheck it.

If a patient has a varicocele, which means dilated veins around the testicle, that’s a surgically correctable cause of high DNA fragmentation. We would treat it. In some patients who have an idiopathic cause, meaning we can’t figure out why their DNA fragmentation is so high, we have some fertility supplements which are that are full of antioxidants, and that’s what we will put them on empirically.

If they’ve had cycles, if none of that has worked, rarely, but we do this, we will do testis biopsy to get the testicular sperm which should have lower DNA fragmentation and do IVF cycles using testicular sperm.

What is the recovery time after the mTESE procedure?

Recovery time is usually about two weeks, so my post-operative instructions are 24 hours of bed rest with plenty of ice, Motrin and Tylenol for the pain, they will wear a jockstrap or scrotal support just tight-fitting underwear.

I recommend that they wear that for at least three days, but most will wear it for up to a week. When it comes to activities, two weeks of no heavy lifting, sexual intercourse, masturbation. After the two weeks, they can reintroduce activities as they feel fit. Certainly, if you’re still having pain take it easy, but again you can get back to running, walking, biking as long as it’s not painful.

Does the insurance cover any of such procedures?

This depends on the state and countries. In Florida, insurance doesn’t cover any of these procedures except for rare circumstances. Some states in the U.S. do cover IUI cycles or IVF cycles, but as far as overseas, I don’t know the details of most of the countries and what their national health plans do.

In men with non-obstructive azoospermia (NOA), how many TESE or mTESE can be done?

In non-obstructive azoospermia, this is the production defect, what it means is that the testicle itself is not producing a lot of sperm. When we do mTESE, the plan is to do one mTESE, and if we find sperm, we use it and freeze whatever is remaining. If they have an unsuccessful cycle, we’re considering a repeat mTESE, if someone had sperm the first time, if on the first mTESE we did not find sperm, I do not do a second mTESE.

If we were successful the first time on mTESE, we’ll consider a repeat. If we were unsuccessful on the first mTESE, I do not consider it a repeat. As far as conventional testis biopsies, I do not recommend them for patients with NOA, but you can perform multiple. If you didn’t find sperm the first time, your chances of finding sperm on a repeat conventional biopsy are very low.

Do you do TESE or mTESE in men with higher hormonal profile, for example, FSH more than 30 UI or small testicles?

It sounds like you’re describing a high FSH in small testicles, which is non-obstructive azoospermia. If you have the capability of performing mTESE, I would recommend mTESE in that instance. I think the guidelines from the ASRM, The American Society of Reproductive Medicine in non-obstructive azoospermia, say that mTESE is the preferred technique. If you’re in an area where no one performs that procedure, then a conventional TESE is what you have to go for, and that’s going to be your best bet.

In patients who consistently are having a low blastocyst number in ICSI cycles can we use testosterone, then is there a need to do a DNA fragmentation test before? What level of fragmentation is the threshold to go for the TESA?

This is a complicated question with many nuances to it, and I don’t want to give you an answer and tell you this is what you should do because there are multiple factors involved, the male side is just half of it. This could also be affected by female parameters. If you do a DNA fragmentation test that shows high fragmentation, again look for causes that may be initially causing it, infection, varicocele. The threshold cut toffs depend on what tests you use.

There are different tests, there’s something called a Comet usually, 30% is about what we use as a cut-off before we would consider, at least initiating some treatment. Before going to a TESE, again we look first for reversible causes before we start trying to use testicular sperm. The reason being testicular sperm having a lower fertilization rate, to begin with. There are risks by going to the testicle and going ejaculated, and I’m assuming ejaculated with sperm was used in these previous ICSI cycles.

What is the role of optimizing testosterone before mTESE?

This gets into some nuance, for the most part, the patients we see with non-obstructive azoospermia have normal testosterone. There are cases such as Klinefelter patients whose testosterone may be lower, and we do try to optimize their testosterones beforehand. The concept is that testosterone is used to get sperm through that last step of maturation. By potentially optimizing the testicle’s testosterone production, we may be increasing our chance of obtaining sperm. In Klinefelter’s patients, it has been shown to increase your chances of sperm retrieval.

Outside Klinefelter in this sort of idiopathic non-obstructive azoospermia, the results are a little more mixed. If they have a low testosterone level, and it appears to be correctable with medical therapy with Clomid or AnastrozoleI would try to increase their testosterones beforehand. I will not use exogenous testosterone, meaning I will not give testosterone gels, patches or any other form because that will decrease the testicular production of testosterone and lower your chances of finding sperm.

What is the maximum value for FSH and LH that could contraindicate TESE?

I don’t know that there is a maximum FSH or a maximum LH. If you look at patients who are not obstructive azoospermia, what you’re looking at is potentially a testicular failure. When the testicle’s not making sperm, the brain senses that and gives the signal FSH to the testicle to tell it to make more sperm. Is there a point where the FSH means that signal is so high that we just say to ourselves there’s no chance we’re going to find sperm, and I don’t know if that data exists yet.

I use these numbers to determine what kind of medical therapies I may use to try and boost testosterone production. If the FSH and LH are over 15 to 20, I’m less confident that putting them on a medication like Clomid or hCG is going to affect them. To summarize, there’s not a cut-off of FSH where I would say there’s no chance we’re going to find sperm.

Have you seen any changes in semen parameters in patients post-COVID? Are there any studies done so far?

Some of my colleagues are working on this paper, so I won’t give you the big results, but so far, it looks like, with COVID-19, it’s like any other febrile disease, so in times of stress or fever, sperm counts do decline transiently afterwards. It takes about three months for a sperm to grow up from the germ cell to an adult sperm, anything that negatively affects sperm production, say you go into hot tubs every day, that’s going to drop the sperm count almost immediately, but it will recover as long as the offending event is removed, so that’s my teaser for this.

 What is your opinion on testicular mapping versus mTESE?

I do not do testicular mapping, I go straight for mTESE. Some people swear by it and think that it will increase your chances of finding sperm, but I trained in a place where we do straight from mTESE, and sperm retrieval rates are similar.

Does sperm DNA fragmentation index (DFI) increase with male ageing? 

DNA fragmentation should not increase with age, assuming you have a healthy individual. The same thing with semen parameters in patients who do not have a chronic disease, diabetes, high blood pressure, metabolic syndrome, sperm counts should remain and should not be declining. It is typically a chronic disease that causes many of these other abnormalities in sperm.

What period do you recommend to wait for IVF in a vaccinated patient? 

I don’t have a great answer for it since I don’t do the actual IVF procedures, I don’t think there’s any data to show that the vaccine is harmful to IVF cycles, but I would ask your particular physician what their thoughts are and what they do, but I don’t believe there’s any contraindication.

What is the typical leftover volume of sample to freeze after a surgical retrieval?

It’s usually not the volume, but you’re looking more at the numbers of sperm. Something to keep in mind is that in the freeze-thaw cycle of sperm, about 50% of them are going to die off. How much is frozen or what you decide to do depends on multiple factors.

If you’re talking about a patient who had mTESE, and maybe you only found 10 sperm, and you used 5 or 10 of them, or you have some leftover, maybe it’s only 1 or 2, it may be worth trying to save those couple of sperm, it may not be, so really it’s a decision made between you and your physician. Some patients don’t want to freeze any of the sperm, they just want to do one and done, and that’s all. Meanwhile, with ejaculated sperm, you may have millions leftover that you may want to freeze, so it’s not one answer.

 Is there a difference in long versus short-acting testosterone on fertility?

To cover what these two things are. Short-acting testosterone is that you take multiple times a day. The two main ones are Nitesto and nasal gel and the new one Jatenzo, which is an oral medication. Compare this to injections which might be once every week to two weeks, pellets which might be once every four to six months.

There is some data to show that the shorter-acting testosterone has less effect on your LH and FSH, as well as semen parameters. Normally, about 60% of guys become azoospermic while on testosterone therapy with the short actings, we don’t see that. We see just small drops in their test in their sperm counts, but they don’t seem to go to zero.

Can we use hCG long term in men with normal testosterone?

No one has really looked at it. I typically don’t give hCG to men who have normal testosterone. If they’re on the low end of the normal, and they have symptoms of low testosterone, we may consider it.

The reason behind some of this is that hCG mimics LH, so theoretically, it should not drive your testosterone levels as high, it should have less effect on your fertility since you’re not suppressing testicular testosterone production. Long-term HCG use there are not studies, but I can tell you at least anecdotally you know people who go to the gym may be using it, and they seem not to have a ton of ill effects from it.

Which testosterone do you test, total or free? 

I screen using just total testosterone if it’s borderline. If the testosterone is around 300, it’s considered to cut off for low. If it’s borderline then I may consider getting free and total on the second since here in the U.S., to get testosterone covered and approved, you need two levels below 300. If there’s any doubt whether it’s low or not, you can get a free to check if the free testosterone is low, and it just supports your diagnosis.

What is the testicular salvage therapy protocol?

What you’re referring to testicular salvage protocol, one form of treatable non-obstructive azoospermia, so in people with production defect is prior testosterone use. In those patients, we don’t do any of these sperm retrieval techniques we would treat medically to try to get their sperm production back in gear.

It’s non-obstructive azoospermia that’s caused secondary to medical therapy. We take them off of the testosterone, and I then place them on hCG three times a week as well as a medication called Clomid. Clomid causes the natural FSH production to increase, and hCG mimics LH, so you’re getting both of those signals to the testicle to try and increase sperm and intratesticular testosterone production.

Can Endo-PRP (endometrium rejuvenation) treatment improve your endometrial thickness?
Do you trust your clinic? Building, training and tuning your BS detector
Fertility preservation & egg freezing: understanding your options
Advanced maternal age & egg donation in Spain: exploring your options
Diagnostic evaluation & management of male infertility
Personal boundaries in your fertility journey: what are they,  how to put them in place, and why you might need them
Thomas A. Masterson, MD

Thomas A. Masterson, MD

Dr Thomas A. Masterson, MD is an Assistant Professor in Urology at the University of Miami and Bruce W Carter VA medical centre in Miami, Florida. Dr Masterson completed his Urology residency at Jackson Memorial Hospital and Fellowship in Reproductive and Sexual Medicine at the University of Miami under the mentorship of Dr Ranjith Ramasamy.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
Have questions about what factors will affect your IVF success?
Join our live event to directly ask your questions to three IVF experts.