Understanding PESA and TESE: Options for Men with Azoospermia

Many couples face challenges when trying to have a baby. Sometimes the issue affects the father, and one of the most common male fertility problems is azoospermia.

Source: WHO estimates 1% of all men and 1015% of infertile men have azoospermia.

What is azoospermia?

Azoospermia simply means there's no sperm in a man's semen. This doesn't necessarily mean he's not producing spermsometimes there's just a blockage preventing the sperm from getting into the semen. The good news is that modern medicine offers solutions through procedures that can retrieve sperm directly from the testicles or connecting tubes.

The two main procedures for this are called PESA and TESE. These procedures are typically used with a fertility technique called ICSI (Intracytoplasmic Sperm Injection), where the retrieved sperm is directly injected into an egg. Let's explore each option in a way that's easy to understand.

Causes of Azoospermia can be divided into two main types, based on the underlying cause of the absence of sperm:

• Obstructive azoospermia occurs when sperm is being produced normally, but a physical blockage prevents it from reaching the semen. This could be due to a prior vasectomy, infection, injury, or a congenital condition.
  
• Non-obstructive azoospermia is related to problems with sperm production inside the testicles. It may be caused by genetic conditions, hormone imbalances, or damage from treatments like chemotherapy or radiation.
  

Understanding PESA (Percutaneous Epididymal Sperm Aspiration)

How it works:

Think of PESA as a straightforward retrieval method. The doctor uses a fine needle to collect sperm from the epididymisa tube behind the testicle where sperm is stored before ejaculation. Picture the epididymis as a "storage reservoir" for mature sperm.

The procedure is quick, done under local anesthesia, and doesn't require any incisions or stitches. Most men experience minimal discomfort and can go home the same day.

Who is it for :

PESA works best for men with "obstructive azoospermia." This means they produce healthy sperm, but something is blocking its path into the semen. Common causes include previous vasectomy, infections, injury, or being born with a structural issue.

Possible risks or complications :

PESA is generally safe, but you might experience:

• Some mild discomfort, swelling, or bruising where the needle was inserted
  
• Rarely, an infection might develop
  
• Sometimes, sperm can't be found using PESA, and doctors may recommend trying TESE instead
  

Understanding TESE (Testicular Sperm Extraction)

How it works :

TESE goes straight to the source. The doctor makes a small incision in the testicle and removes a tiny sample of tissue. This sample is examined under a microscope to find viable sperm. The procedure is performed under local or general anesthesia, depending on what works best for you.

For men with "non-obstructive azoospermia," the issue isn't a blockage but rather difficulties with sperm production. Even when sperm production is minimal or limited to certain areas of the testicle, TESE can often locate those few precious sperm cells needed for fertility treatment.

Who is it for :

TESE is recommended for men with non-obstructive azoospermia, which doctors typically confirm through hormone tests and semen analysis. This includes men with genetic conditions like Klinefelter syndrome, those who've undergone cancer treatments, or men with testicular tissue damage due to injury or developmental issues.

Possible risks or complications :

Since TESE is more invasive than PESA, potential risks include:

• More significant swelling or discomfort after the procedure
  
• Possible internal bleeding or bruising within the testicle
  
• Despite the procedure, viable sperm might not be found in some cases of severe production issues
  

Differences Between PESA and TESE

The main differences between these procedures come down to:

• What type of azoospermia you have (obstructive vs. non-obstructive)
  
• How invasive the procedure is (needle aspiration vs. tissue extraction)
  
• Recovery time (generally quicker for PESA)
  
• Success rates (which vary based on your specific condition)
  

Your fertility specialist will recommend the most appropriate option based on your individual situation, giving you the best chance of finding sperm that can be used for fertility treatment.

1. ICSI is Essential for PESA/TESE Procedures
   When sperm is retrieved through procedures like PESA or TESE, the number of sperm collected is often very limited, and may not be suitable for conventional IVF. This is where ICSI (Intracytoplasmic Sperm Injection) becomes essential, as it allows a single healthy sperm to be injected directly into an egg, significantly increasing the chance of fertilization.
2. Sperm Freezing (Cryopreservation)
   Sperm freezing, or cryopreservation, is a safe and effective method for preserving male fertility. The collected sperm is frozen and stored for future use in fertility treatments such as ICSI or IVF.