MicroTESE (TESE-TESA)

Micro TESE

Micro TESE is a specialized surgical procedure designed to retrieve sperm from the testes using microscopic techniques in men with absent or severely diminished sperm production. At the Ivox IVF Center in Cyprus, our urology and embryology teams perform Micro TESE with precision, safety, and high success rates.

What is Micro TESE?

Micro TESE (Microsurgical Testicular Sperm Extraction) is the process of searching for and extracting sperm under microscopic guidance in men where sperm production is insufficient or limited to specific focal points. This method is particularly indicated for men diagnosed with non-obstructive azoospermia (NOA).

Unlike traditional TESE methods, Micro TESE utilizes an operating microscope (typically with 20–25x magnification) to examine the testicular tissue in detail. The goal is to distinguish the seminiferous tubules that are actively producing sperm and sample the most productive tissue to obtain viable sperm cells.

Because it directly targets productive tubules, Micro TESE both increases the sperm retrieval rate (50–65%) and minimizes damage to the testicular tissue.

Objectives of the Microsurgical TESE Procedure

The primary objective of Micro TESE is to isolate viable sperm cells directly from the testis and make them available for ICSI (Intracytoplasmic Sperm Injection) in the laboratory.

The procedure is performed on men who do not have a blockage in the sperm ducts but still have no sperm in their semen. By selectively removing tissue at a microscopic level, both the yield and the structural integrity of the tissue are preserved.

• Did you know? Every testis contains millions of seminiferous tubules, but sperm may only be produced in a few specific clusters. These productive “islands” are often only visible under a microscope.

When is Traditional TESE Not Enough?

Traditional TESE involves surgically removing random tissue samples from the testis. However, this approach carries several risks:

• A high risk of taking samples from areas with no production.

• Extensive tissue removal that can negatively impact testicular function.

• A lower probability of finding sperm (30–40%).

Micro TESE, on the other hand, detects the presence of spermatogenesis directly through the microscope. This allows the surgeon to focus exclusively on the productive tubules.

Microsurgery is considered essential, especially for patients with high FSH levels or small testicular volume. Furthermore, Micro TESE:

• Can distinguish between sclerotic (damaged) tissue and productive regions.

• Offers a chance to find sperm even in patients who have had previously unsuccessful TESE attempts.

• Carries the potential to capture viable sperm even in cases of genetic azoospermia.

What is the Difference Between TESA, TESE, and Micro TESE?

TESA, TESE, and Micro TESE are three distinct surgical methods aimed at retrieving sperm from the testis. Each is applied according to different patient profiles and sperm production levels. The method chosen depends on both the patient’s diagnosis and the biological structure of the testicular tissue.

Technical Differences in Micro TESE and Other Methods

The choice of surgical sperm retrieval method depends on the patient’s specific diagnosis and the biological structure of the testicular tissue.

Surgical Methods Comparison Table

• TESA: The least invasive method, performed under local anesthesia. However, it is often insufficient for cases with severely limited sperm production.

• TESE: Involves a surgical incision for broader tissue sampling, yet the selection remains random.

• Micro TESE: The gold standard for challenging cases like non-obstructive azoospermia. Using a high-resolution surgical microscope, only the tubules showing active spermatogenesis are targeted. This maximizes success while minimizing tissue damage.

Which Method is Right for Which Patient?

• TESA $\rightarrow$ Obstructive Azoospermia: (Ducts are blocked, but production is normal).

• TESE $\rightarrow$ Mixed Cases: (Mild production issues or specific productive areas are present).

• Micro TESE $\rightarrow$ Non-Obstructive Azoospermia: (Severe production disorders).

While simple aspiration methods suffice for obstructive cases, microsurgery is essential for patients with primary production problems.

Additional Key Differences

• Tissue Damage: Micro TESE results in minimal tissue loss. Traditional TESE carries a higher risk of removing healthy tissue.

• Anesthesia: TESA is performed under local anesthesia, while TESE and Micro TESE typically require general anesthesia for patient comfort and surgical precision.

• Recovery: Recovery after Micro TESE is more controlled and faster due to the targeted nature of the tissue removal.

• Lab Compatibility: Micro TESE provides the highest quality sperm, ideal for the ICSI (Microinjection) process.

Why is Micro TESE Preferred?

• Highest sperm retrieval rates.

• Minimal damage to the blood supply and structure of the testis.

• Preserves the possibility of future repeat surgeries.

• Lower risk of post-surgical hormonal imbalances.

At Ivox IVF Center, Micro TESE is performed exclusively by academically trained andrology surgeons using advanced operating microscopes.

Who is Eligible for Micro TESE?

Micro TESE is primarily recommended for men with Non-Obstructive Azoospermia (NOA)—cases where sperm production is either nearly non-existent or limited to microscopic focal points within the testis.

Indications for Micro TESE:

• Non-Obstructive Azoospermia (NOA): Focal sperm production within the testis.

• Testicular Failure: Primary or secondary loss of testicular function.

• Klinefelter Syndrome: Men with an XXY chromosome structure where production is highly limited.

• Y-Chromosome Microdeletions: Particularly in men with AZFc region deletions.

• Post-Chemotherapy or Radiotherapy: Where spermatogenesis has been damaged.

• History of Undescended Testes: Which can negatively impact long-term production.

At Ivox IVF Center, we do not recommend Micro TESE without a comprehensive genetic, hormonal, and urological evaluation tailored to each patient.

How Do Genetic Factors Influence Treatment Decisions?

Genetic anomalies are responsible for 15–30% of azoospermia cases. Before proceeding with Micro TESE, patients must undergo genetic screening, including Y-chromosome microdeletion and karyotype analysis.

• AZFc Deletion: There is a good chance (up to 50%) of retrieving sperm via Micro TESE.

• AZFa or AZFb Deletion: The probability of finding sperm is extremely low (near 0%).

• Klinefelter Syndrome: The success rate of retrieving sperm increases significantly if the procedure is performed at a younger age.

Genetic diagnosis is essential both to predict treatment success and to assess the risk of transmitting genetic conditions to future offspring.

Is Micro TESE Suitable for Every Azoospermia Patient?

No. Micro TESE is only recommended for patients where sperm production is very low but not entirely absent. It is typically not performed in the following cases:

• Sertoli Cell Only Syndrome: If all tubules lack sperm-producing cells.

• Testicular Fibrosis: If the tissue is completely damaged or scarred.

• Complete AZFa or AZFb Deletion: If sperm production is genetically impossible.

In these specific groups, standard TESE or TESA will also fail, and alternative options (such as donor sperm) should be considered.

Key Parameters in Patient Evaluation

Before deciding on Micro TESE, the following criteria are analyzed in detail:

How is Micro TESE Performed?

Micro TESE is a microsurgical operation where sperm-producing tubules within the testicular tissue are identified under a microscope and sampled. The procedure is performed under general anesthesia in sterile operating room conditions.

The goal is to increase retrieval chances while minimizing tissue trauma by sampling only from productive areas.

Procedural Steps:

1. Patient Preparation: Hormone tests, genetic analysis, and ultrasounds are completed. Anesthesia is administered on the day of surgery.

2. Surgical Incision: A small incision is made on the scrotum to access the testis.

3. Opening the Testis: The testicular capsule (tunica albuginea) is carefully opened under microscopic guidance.

4. Microscopic Examination: Seminifer tubules are examined at 20–25x magnification.

5. Tissue Sampling: Only the tubules that appear productive are removed in tiny fragments.

6. Laboratory Transfer: The tissue is immediately sent to embryologists to search for sperm.

7. Processing: If sperm is found, it is either used for fresh ICSI or frozen at -196°C for future use.

8. Closing: The capsule and skin layers are closed with aesthetic (absorbable) sutures.

The Role of the Surgical Microscope

The surgical microscope allows the surgeon to see differences in color, thickness, and fullness among the tubules:

• Productive Tubules: Generally opaque, fuller, and more convoluted.

• Non-productive Tubules: Thin, transparent, and straight.

Without a microscope, these differences are indistinguishable. This is why Micro TESE can succeed even when a traditional TESE has previously failed.

Duration of the Procedure

• The Micro TESE operation typically lasts between 1.5 to 3 hours.

• The duration depends on the tissue structure and the time required for a thorough search.

• Both testes can be examined during the same session if necessary.

At Ivox IVF Center, the urologist and embryologist work in real-time synchronization to ensure the highest possible yield during the surgery.

What Happens if No Sperm is Found?

In cases where sperm is not immediately identified, the retrieved tissue is re-analyzed using advanced laboratory techniques. If the results remain negative:

• Sperm Donation: The option of using donor sperm is discussed with the couple.

• Hormonal Stimulation: Hormone therapies aimed at stimulating potential sperm production may be recommended for future attempts.

• Consultation: Our specialists work closely with the patient to determine the most suitable next steps for their fertility journey.

Duration and Recovery Timeline

The Micro TESE procedure typically lasts between 90 and 180 minutes. This timeframe is necessary for the microscopic search, ensuring every productive tubule is carefully examined.

• Discharge: Patients are generally discharged on the same day. After a few hours of clinical observation, you can return home.

• Sutures: We utilize self-dissolving sutures, meaning there is no need for a follow-up appointment for stitch removal.

Post-Operative Recovery: What to Expect

Recovery is typically fast and manageable. Most patients return to their daily routines within 3 to 5 days.

Guidelines for a Smooth Recovery:

1. Sexual Activity: Avoid sexual intercourse for at least 1 week.

2. Physical Exertion: Refrain from heavy lifting or strenuous exercise for 3–5 days.

3. Heat Exposure: Avoid hot baths, saunas, or steam rooms for 10 days.

4. Medication: Use prescribed antibiotics and pain relievers strictly as directed by your physician.

Managing Pain and Swelling

Mild pain, bruising, and swelling in the scrotum are normal and usually peak within the first 48 hours before subsiding.

Note: If you experience sudden, intense pain, high fever, or unusual discharge, please contact your doctor immediately.

Returning to Work and Daily Life

• Office-based Work: You can typically return to work within 2–3 days.

• Physical Labor: For jobs requiring physical effort, a rest period of at least 5–7 days is recommended.

Because Micro TESE minimizes tissue damage, the recovery process is significantly faster and more comfortable compared to traditional TESE methods.

What is the Success Rate of Micro TESE?

The sperm retrieval rate for Micro TESE ranges between 30% and 65%, depending on the patient’s clinical condition. The highest success is achieved in patients with non-obstructive azoospermia who have focal sperm production within the testicular tissue.

At Ivox IVF Center, our advanced microscopy technology and multidisciplinary approach ensure success rates that are on par with global standards.

Which Factors Influence Sperm Retrieval Rates?

Several key parameters directly impact the likelihood of finding viable sperm during Micro TESE:

For example: While the success rate for a young male with a regional AZFc deletion can go as high as 60%, the chances of finding sperm in a patient with an AZFa deletion are near zero.

Average Success Rates by Patient Group

At Ivox IVF Center, we apply personalized treatment algorithms for patients with genetic risks. Timely intervention in the right candidate significantly improves outcomes.

What Happens if No Sperm is Found?

If sperm is not identified during the initial search:

• Advanced Analysis: The tissue is sent for specialized laboratory processing and re-analysis.

• Genetic Re-evaluation: The genetic profile is reassessed for any missed details.

• Alternative Options: Options such as donor sperm or embryo donation are discussed with the couple.

• Hormonal Pre-treatment: A second attempt may be planned following a period of hormonal stimulation.

Sperm obtained through Micro TESE can be used fresh or frozen. Fertilization rates with frozen TESE sperm are equivalent to those achieved with fresh samples.

How is Sperm Obtained via Micro TESE Used?

Viable sperm cells isolated from the testis are used directly via ICSI (Intracytoplasmic Sperm Injection). In this process, a single healthy sperm is injected into each retrieved egg.

The ultimate goal of Micro TESE is not just finding sperm, but ensuring the quality of the cells is sufficient to develop into healthy, viable embryos.

Is Sperm Obtained via Micro TESE Used Immediately?

Yes, if the female partner’s egg retrieval is scheduled for the same cycle, fresh sperm can be used directly. However, sperm is often preserved using cryopreservation (freezing) in the following scenarios:

• If the egg retrieval is scheduled for a different date.

• If sperm is found but fertilization is planned for a later time.

• If the couple wishes to store sperm for future treatment attempts.

At Ivox IVF Center, the sperm freezing process is safely conducted in liquid nitrogen tanks at -196°C.

How Does the ICSI Process Work with Micro TESE Sperm?

The transition from surgery to the laboratory involves a highly specialized path:

1. Sperm Selection: Embryologists meticulously isolate viable, motile, or structurally sound sperm from the Micro TESE tissue.

2. Egg Retrieval: Following hormonal stimulation, the mother’s eggs are collected.

3. Microinjection: A single sperm is injected into each egg using a specialized microneedle.

4. Fertilization & Culture: The resulting embryos are monitored for 3–5 days in a controlled environment.

5. Transfer: The highest-quality embryo is placed into the uterus.

This method allows couples to have their own genetic child as long as even a few viable sperm cells are found in the testis, regardless of the absence of sperm in the semen.

Fresh vs. Frozen Sperm: Is There a Difference?

No. Clinical studies show that fertilization, embryo quality, and pregnancy rates achieved with frozen Micro TESE sperm are very close to those achieved with fresh samples.

Ivox IVF Center utilizes advanced cryoprotectants and thawing techniques to maximize sperm viability after freezing.

How Much Does Micro TESE Cost?

The cost of Micro TESE varies depending on the clinical complexity, laboratory requirements, and additional procedures. As of 2025, the estimated cost ranges between €1,800 and €3,500.

Factors Affecting the Cost:

• Type of Anesthesia: Whether local or general anesthesia is required.

• Bilateral Search: Whether the procedure needs to be performed on both testes.

• Cryopreservation: Fees for freezing and long-term storage of sperm.

• Treatment Integration: Package deals that combine Micro TESE with the ICSI cycle.

Insurance and Coverage

Procedures performed at private IVF centers in Cyprus are generally not covered by the Social Security Institution (SGK) of Turkey. However, some international private health insurance policies may cover the surgical portion of Micro TESE. Coverage depends entirely on the specific terms of the patient’s insurance policy.