Surgical Sperm Retrieval: A Comprehensive Guide to Your Options
Critical Prerequisites Before Considering Surgery
Surgery is a serious decision with potential lifelong negative impacts. Before considering any surgical sperm retrieval, ensure you have completed ALL of the following:
Essential Testing and Waiting Periods
- Multiple semen analyses: At least two analyses separated by several months
- Extended sperm search: At least one comprehensive search of your entire semen sample
- Hormone optimization: Blood tests confirming normal hormone levels, with several months of treatment and waiting if levels were abnormal
- Testosterone history: Never taken testosterone replacement therapy, or if you have, you've stopped for an extended period (many months or years), and potentially used hCG.
- Finasteride consideration: If you were taking finasteride, stopped for an extended period before repeating semen analyses
- Genetic testing: Confirmed you do not have a complete Y-chromosome AZFa or AZFb deletion
- Obstruction verification: If FSH isn't extremely elevated, confirmed you don't have obstructive azoospermia (or ensure your doctor will perform needle biopsy before starting the more invasive surgery)
You should only consider surgery after completing this entire checklist. The decision for surgery is extremely serious and irreversible.
Surgical Options
TESA/PESA (Least Invasive)
Procedure: Inserting a fine needle into the testicle (TESA) or epididymis (PESA) to aspirate tissue and fluid.
Anesthesia: Usually local anesthesia or light sedation
Best For: Obstructive azoospermia (lower success rates for non-obstructive cases)
Recovery: Less invasive surgery means limited recovery time.
Chances for success: For men with obstructive azoospermia, TESA/PESA has near a 100% success rate at collecting sperm. For men with non-obstructive azoospermia, TESA finds sperm in around 20% of cases.
MicroTESE
Most urologists in 2025 typically recommend microTESE for men with non-obstructive azoospermia. The full name of the procedure is sometimes referred to as microsurgical, microscopic, or microdissection testicular sperm extraction.
- The Consensus: For non-obstructive azoospermia, no surgical technique finds sperm more often than microTESE. This is almost universally agreed on.
- The Controversy: Significant debate exists regarding specific techniques and lifelong side effects, leading some doctors to recommend alternative approaches.
- The Reality: MicroTESE is hard on the testicles. This is a major decision requiring careful consideration of pros, cons, and your surgeon's specific techniques.
Potential complications from microTESE
MicroTESE surgery carries significant risks that may affect you for life. Potential complications include permanent testicular damage, chronic pain, testicular shrinkage (atrophy), decreased testosterone production requiring lifelong hormone replacement therapy, and impact on remaining natural fertility. Some men experience long-term discomfort, changes in testicular sensation, or psychological effects from the physical changes. The deeper the surgical dissection into testicular tissue, the higher the risk of these complications. While success rates for finding sperm are important, these potential lifelong consequences must be carefully weighed against the possibility of surgical failure. Recovery can take weeks to months, and some effects may not become apparent until years later. Understanding these risks is crucial for making an informed decision about whether to proceed with surgery.
Critical Question for Your Surgeon
Is an Embryologist Present During Surgery?
The Wrong Approach: Some surgeons perform complete surgeries on both testicles before sending samples to a lab for sperm examination. This is absolutely not recommended as it doesn't minimize patient harm.
The Right Approach: An embryologist should examine tissue during surgery so that if sperm is found, the procedure can be stopped immediately, preventing unnecessary additional damage.
Ask your surgeon: "Will an embryologist be present during surgery to enable you to stop if sperm is found?"
The Periphery-Only vs Full Dissection Debate
Understanding Standard MicroTESE Evolution
TESE (Repeated biopsies)
This was the technique used for the first ~10 years after advanced IVF capabilities called ICSI was developed, allowing embryos to be formed with just a single sperm. This technique involved making multiple random slices from the outside of both testicles, then examining the slices for sperm.
MicroTESE, first performed in 1999, made two key changes from previous TESE methods:
- Used a microscope to identify enlarged tubules and take much smaller cuts
- Cut deep inside the testicle instead of staying only on the periphery
It's well established that microTESE made significant improvements to the rate of men who had sperm found (roughly from 25% with TESE to 50% with microTESE).
While microTESE showed higher sperm retrieval rates than traditional TESE, it's unknown how much (if any) benefit comes from cutting deep into the testicle vs taking a more exhaustive sampling of healthy looking seminiferous tubules.
The Case for Periphery-Only MicroTESE
The Biological Logic:
- Testicles contain approximately 300 tubules, each tightly coiled
- When sperm exists somewhere in a tubule, it likely exists throughout that entire tubule
- Sperm production is self-replicating—if sperm is made, additional sperm stem cells must be produced. If sperm exists in the tubule it would naturally spread within that tubule.
- Evidence shows all (or nearly all) tubules radiate outward from the testicle center and touch the periphery before returning to center
The Conclusion: If sperm exists throughout tubules AND all tubules touch the periphery, then periphery-only microTESE (pomTESE) should achieve equivalent success rates with far less risk of lifelong, irreversible testicular damage.
Doctors Offering Periphery-Only Techniques
Dr. Silber - St. Louis
- Only offers surgery combined with full IVF cycle
- Dr. Silber is in his 80s, so has a lot of experience but likely won't be doing surgeries in 10 more years.
Dr. Werthman - Los Angeles
- Technique likely doesn't sample all tubules, potentially less effective than Dr. Silber's approach
Research Need: Due to microTESE's development history, periphery-only microTESE has never been directly compared to standard microTESE. More doctors and research are needed in this area.
Additional Considerations
Salvage MicroTESE
If your first microTESE failed to find sperm, you may consider a second procedure. This decision is extremely difficult to evaluate. Some studies show success after previous failed microTESE, but results are somewhat questionable.
Cost Considerations
Cheapest Option: Salt Lake City offers the most affordable surgical sperm retrieval in the country at $2,750 for microTESE. If insurance doesn't cover costs and finances are a concern, consider: https://malefertilityandpeyroniesclinic.com/microtese-home/
Successful births with surgically retrieved sperm
Even if sperm is found, the battle is only half over. There are a lot of problems using surgically retrieved sperm. On average, only about half the couples who successfully have surgically retrieved sperm will have a successful full-term pregnancy with a live birth. One of the most sobering statistics: Of 100 men going in for microTESE surgery, 50 will find sperm, and out of those 50, only about 25 will end up with a baby. The low chance of ultimate success should be a consideration with your journey.