TESA and PESA Explained
TESA and PESA are minimally invasive sperm-retrieval procedures most commonly used when sperm production is preserved but sperm cannot reach the ejaculate. PESA (percutaneous epididymal sperm aspiration) takes sperm from the epididymis using a needle; TESA (testicular sperm aspiration) samples sperm-containing tissue directly from the testis. Both can provide sperm for ICSI in obstructive azoospermia. They are not equivalent to micro-TESE: in non-obstructive azoospermia, needle aspiration has lower retrieval and current EAU guidance favours micro-TESE instead.
TESA versus PESA: quick comparison
| Feature | PESA | TESA |
|---|---|---|
| Where sperm are taken from | Epididymis | Testis |
| Typical indication | Obstructive azoospermia with accessible epididymal sperm | Obstructive azoospermia or backup when epididymal retrieval is unsuitable |
| Anaesthesia | Usually local anaesthesia ± sedation | Usually local anaesthesia ± sedation |
| Incision | Needle puncture; no formal scrotal incision | Needle puncture; no formal scrotal incision |
| Sperm quantity | Variable; may yield enough for several ICSI uses in some cases | Variable; often fewer sperm than open TESE |
| Role in NOA | Not appropriate when epididymal sperm are absent because production is impaired | Not recommended as definitive retrieval in NOA; micro-TESE preferred |
What is PESA?
A fine needle is passed through the scrotal skin into the epididymis. Gentle suction aspirates fluid, which is immediately examined by the embryology team for sperm. More than one puncture may be needed to obtain adequate sperm. PESA is quick and minimally invasive but can yield less sperm than microsurgical epididymal sperm aspiration (MESA).
What is TESA?
A biopsy/aspiration needle is passed into the testis and small fragments of seminiferous tubules are aspirated. The embryologist processes the tissue and searches for sperm. In true obstructive azoospermia, testicular sperm production is preserved and TESA can often retrieve usable sperm.
Who is a good candidate?
- Congenital bilateral absence of the vas deferens.
- Vasectomy-related obstruction when the couple chooses sperm retrieval + IVF/ICSI instead of reversal.
- Epididymal/vas obstruction from previous infection or surgery.
- Selected ejaculatory disorders where ejaculated sperm cannot be obtained.
- Men needing a planned backup retrieval for an IVF/ICSI cycle when obstruction is established.
Why not use TESA for non-obstructive azoospermia?
NOA is a patchy sperm-production problem. A needle samples only small random areas and can easily miss focal spermatogenesis. EAU guidance reports lower retrieval with TESA than TESE and specifically recommends against TESA in NOA, favouring micro-TESE when surgery is appropriate.
When is reconstruction better than retrieval?
A man with an acquired surgically correctable obstruction may have two pathways: reconstruction to restore sperm to the ejaculate, or retrieval with IVF/ICSI. Reconstruction can be attractive when the female partner has good fertility and the couple wants more than one child. Retrieval may be faster when IVF is already needed for female factors or reproductive time is limited.
Fresh versus frozen sperm
In obstructive azoospermia, retrieved sperm can often be cryopreserved in advance because the chance of finding sperm is generally high. This avoids linking the male procedure to the exact day of oocyte retrieval. The embryology laboratory should confirm that enough viable sperm are stored.
Recovery and risks
Most men go home the same day. Mild pain, bruising and swelling are common for a few days. Risks include haematoma, infection, pain and, with epididymal aspiration, local epididymal injury or scarring. Extensive repeated testicular punctures should be avoided when a more definitive retrieval strategy is appropriate.
How a urologist chooses PESA, TESA, MESA or TESE
The decision depends on the site/cause of obstruction, need for sperm quantity, planned number of IVF cycles, previous surgery and local embryology expertise. In some men, PESA is attempted first and TESA is used as backup. In others, MESA or open TESE provides a larger planned sperm yield for freezing.
How PESA is performed
A fine needle is passed through the scrotal skin into the epididymis under anaesthesia. Fluid is gently aspirated and handed immediately to the embryology laboratory. In a man with obstructive azoospermia, epididymal sperm can be abundant; if the first aspiration is inadequate, another epididymal site or a testicular retrieval can be used.
How TESA is performed
A needle is passed into the testis and small cores or fragments of seminiferous tissue are aspirated. The embryology team teases the tissue apart to identify sperm. TESA is useful in selected obstructive cases, but it is not the preferred retrieval technique for non-obstructive azoospermia because random needle sampling can miss focal sperm production.
Planning with the IVF laboratory
The procedure should be coordinated with an embryology laboratory capable of processing surgically retrieved sperm. In predictable obstruction, sperm are often retrieved and frozen before the female partner’s cycle, reducing the risk of discovering an unexpected male problem on the day of oocyte retrieval. The number of vials stored and post-thaw viability should be documented.
Choosing PESA, TESA or micro-TESE
PESA samples the epididymis and is mainly useful when sperm production is expected to be normal but the reproductive tract is obstructed. TESA samples the testis with a needle and can also retrieve sperm in many obstructive cases. Non-obstructive azoospermia is different: because sperm production may exist only in tiny focal areas, guidelines generally favour micro-TESE when surgical retrieval is appropriate rather than repeated blind needle aspirations.
The best procedure depends on the site and cause of obstruction, previous vasectomy or surgery, whether reconstruction is being considered, how much sperm the IVF laboratory needs and whether enough can be frozen for future cycles. Retrieved epididymal or testicular sperm are generally used with ICSI rather than simple insemination.
In obstructive azoospermia, sperm can often be obtained from either the epididymis or testis. The choice may depend on whether the epididymis is accessible, how much sperm is needed for freezing, previous surgery and local laboratory expertise. The retrieval plan should be coordinated with the IVF laboratory before the procedure rather than decided after sperm are obtained.
PESA and TESA are usually shorter and less invasive than open microsurgical retrieval, and many cases can be performed with local anaesthesia or short anaesthesia depending on the setting. Mild soreness and bruising can occur afterwards. The simplicity of a needle technique, however, should not be confused with suitability: the wrong retrieval method can lead to repeated procedures or inadequate sperm for the planned IVF cycle.
Emergency warning signs
After TESA or PESA, seek urgent review for rapidly increasing swelling, severe worsening pain, persistent bleeding, fever or spreading redness. Mild tenderness or bruising at the puncture site is usually less concerning.
What to bring for consultation
Bring these if available:
- Semen reports confirming azoospermia.
- FSH/testosterone and physical examination findings.
- Any CFTR or genetic reports.
- Vasectomy/hernia/scrotal surgery records.
- Prior sperm retrieval and cryopreservation report.
- IVF laboratory plan and oocyte retrieval schedule.
- Blood thinner/medical history.
FAQs
Is PESA painful?
It is usually performed with local anaesthesia. Brief soreness or bruising can occur afterward.
Which is better, TESA or PESA?
Neither is universally better. PESA accesses epididymal sperm; TESA accesses testicular sperm. The cause of obstruction and sperm quantity needed determine the choice.
Can TESA be done for non-obstructive azoospermia?
It can sample testicular tissue, but current EAU guidance does not recommend it as the retrieval method for NOA because success is lower than micro-TESE.
Can PESA sperm be frozen?
Yes if enough viable sperm are recovered. Freezing is commonly used in obstructive azoospermia.
Does TESA reduce testosterone?
A limited aspiration usually removes little tissue, but bleeding and tissue injury are possible. Extensive retrieval in already abnormal testes is a different situation.
Do I need IVF after PESA/TESA?
Retrieved epididymal or testicular sperm are generally used with ICSI rather than ordinary intercourse or standard IUI.
Related reading
- Obstructive Azoospermia
- Azoospermia: No Sperm in Semen
- Micro-TESE Surgery Explained
- Sperm Freezing: When Should Men Consider It?
- Genetic Testing in Male Infertility
- Urologist in Latur
References
- European Association of Urology. EAU Guidelines on Sexual and Reproductive Health: Male Infertility. 2026 https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/male-infertility
- American Urological Association/American Society for Reproductive Medicine. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline (2020; Amended 2024) https://www.auanet.org/documents/Guidelines/PDF/2024%20Guidelines/Male%20Infertility%20Unabridged%20Final.pdf