Indications for Surgical Sperm Retrieval (SSR): Complete Guide

Male infertility is a significant contributor to couple infertility worldwide

• Azoospermia affects approximately 1% of men and 10–15% of infertile males

• Surgical sperm retrieval provides access to sperm when ejaculation fails to do so

• The introduction of ICSI has expanded the indications for SSR

• SSR plays a critical role in modern assisted reproductive technology

Azoospermia affects approximately 1% of the general male population

• Present in 10–15% of infertile men

• Major cause of severe male factor infertility

• Historically considered untreatable before the advent of ICSI

• Surgical sperm retrieval has significantly improved reproductive outcomes in these patients

What is Surgical Sperm Retrieval (SSR)?

• Surgical Sperm Retrieval (SSR) refers to techniques used to obtain sperm directly from the epididymis or testis

• Performed when no sperm are present or usable in the ejaculate

• Retrieved sperm are primarily used for Intracytoplasmic Sperm Injection (ICSI)

• Can be performed as:

• Percutaneous procedures

• Open surgical procedures

Common SSR Techniques:

• PESA – Percutaneous Epididymal Sperm Aspiration

• MESA – Microsurgical Epididymal Sperm Aspiration

• TESA – Testicular Sperm Aspiration

• TESE – Testicular Sperm Extraction

• micro-TESE – Microsurgical Testicular Sperm Extraction

Why is Surgical Sperm Retrieval Needed?

• Failure of sperm to appear in ejaculate due to obstruction

• Impaired or absent sperm production due to testicular dysfunction

• Inability to ejaculate sperm despite production

• Congenital or acquired abnormalities of the male reproductive tract

• Need for higher-quality sperm for use in assisted reproduction

Pre-SSR Evaluation

Clinical history

Duration of infertility
History of cryptorchidism, infections, trauma or surgery
Exposure to chemotherapy, radiation, or gonadotoxins

Semen analysis

Minimum of two samples confirming azoospermia
Centrifuged semen examination to rule out cryptozoospermia

Hormonal profile

Serum FSH, LH, Testosterone and Prolactin
Helps differentiate obstructive vs non-obstructive causes

Imaging

Scrotal ultrasound to assess testicular volume and epididymis
Transrectal ultrasound (TRUS) in suspected obstruction

Genetic evaluation

Karyotype analysis
Y-chromosome microdeletions
CFTR mutation testing (in CBAVD)

Testicular biopsy (selected cases)

When diagnosis remains uncertain
Helps guide choice of SSR technique

Classification of Azoospermia

Azoospermia is classified based on whether sperm production is normal or impaired and whether an obstruction is present in the reproductive tract.

1. Obstructive Azoospermia (OA)

Definition:

Normal spermatogenesis with blockage in the sperm outflow tract.

Common causes:

•Vasectomy
•Congenital bilateral absence of vas deferens (CBAVD)
•Epididymal obstruction
•Ejaculatory duct obstruction
•Post-infectious or post-surgical scarring

Clinical features:

•Normal testicular size and consistency
•Normal serum FSH and testosterone
•Normal secondary sexual characteristics

Implications:

•High likelihood of successful sperm retrieval
•Epididymal or testicular sperm can be used for ICSI
•Genetic evaluation important (e.g., CFTR mutations in CBAVD)

2. Non-Obstructive Azoospermia (NOA)

Definition:

Failure or severe impairment of spermatogenesis within
the testes.

Common causes:

Sertoli cell-only syndrome
Maturation arrest
Hypospermatogenesis
Klinefelter syndrome
Y-chromosome microdeletions
Testicular damage due to chemotherapy, radiation, or
toxins

Clinical features:

Small or soft testes
Elevated serum FSH
May have hormonal imbalance

Implications:

Sperm production may be focal and sparse
Sperm retrieval rates are lower than OA
Best managed with microsurgical techniques (micro
TESE)

Feature	Obstructive Azoospermia (OA)	Non-Obstructive Azoospermia (NOA)
Primary problem	Blockage in sperm transport	Defective sperm production
Spermatogenesis	Normal	Impaired or absent
Testicular size	Normal	Small or soft
Serum FSH	Normal	Elevated
Semen volume	Usually normal	Normal or reduced
Fructose in semen	Present	Present
Genetic association	CFTR mutations (CBAVD)	Klinefelter, Y-microdeletions
Histology	Normal seminiferous tubules	SCO, maturation arrest, hypospermatogenesis
SSR success rate	Very high (>90%)	Moderate (30–50%)
Preferred technique	PESA / MESA / TESA	micro-TESE
Need for ICSI	Yes	Yes
Prognosis	Excellent	Variable

Indication 1: Obstructive Azoospermia (OA)

Definition:

Presence of normal spermatogenesis with blockage in the
sperm transport pathway preventing sperm from appearing
in the ejaculate.

Common Causes

•Vasectomy
•Congenital bilateral absence of vas deferens (CBAVD)
•Epididymal obstruction
•Ejaculatory duct obstruction
•Post-infectious scarring (e.g., TB, STDs)
•Post-surgical injury

Clinical Features

•Normal testicular size and consistency
•Normal serum FSH and testosterone
•Normal secondary sexual characteristics
•Often normal semen volume (except ejaculatory duct
obstruction)

Rationale for SSR in OA

•Sperm production is normal
•Obstruction prevents natural ejaculation
•SSR bypasses the obstruction and retrieves viable
sperm
•Retrieved sperm are suitable for ICSI

Expected Outcomes

•High sperm retrieval rate (>90%)
•Good fertilization and pregnancy outcomes
with ICSI
•Prognosis is excellent compared to NOA

Preferred Techniques

•PESA (Percutaneous Epididymal Sperm
Aspiration)
•MESA (Microsurgical Epididymal Sperm
Aspiration)
•TESA / TESE (if epididymal retrieval fails)

Indication 2: Non-Obstructive Azoospermia (NOA)

Definition:

Absence of sperm in ejaculate due to impaired or absent
spermatogenesis within the testes.

Common Causes

•Sertoli cell-only syndrome
•Maturation arrest
•Hypo-spermatogenesis
•Klinefelter syndrome
•Y-chromosome microdeletions
•Testicular damage due to chemotherapy, radiation, or toxins
•Severe varicocele (selected cases)

Clinical Features

•Reduced or soft testicular volume
•Elevated serum FSH
•Possible hormonal imbalance
•May have associated genetic abnormalities

Rationale for SSR in NOA

•Spermatogenesis may be focal and patchy
•Small areas of active sperm production can exist
•SSR aims to locate and retrieve sperm from these foci
•Enables biological parenthood in selected cases

Expected Outcomes

•Sperm retrieval rate: 30–50% (variable)
•Fertilization possible with ICSI
•Prognosis depends on histology and etiology

Preferred Technique

•Microsurgical Testicular Sperm Extraction
(micro-TESE)
→ higher retrieval rates
→ minimal tissue loss
→ better identification of active tubules

Why micro-TESE is Preferred in NOA Rationale:

•In NOA, spermatogenesis is often focal and sparse
•Conventional TESE may miss small areas of active sperm production

Advantages of micro-TESE

•Performed under an operating microscope
•Allows identification of dilated, opaque seminiferous tubules
•Targets areas more likely to contain sperm
•Avoids random and excessive tissue removal

Clinical Benefits

•Higher sperm retrieval rate compared to conventional TESE
•Reduced testicular tissue damage
•Lower risk of postoperative complications
•Better preservation of testicular function

Indications for micro-TESE

•Non-obstructive azoospermia
•Previous failed TESE
•Genetic causes with residual spermatogenesis
•Severe testicular atrophy

Indication 3: Severe Oligozoospermia

Definition:

Presence of extremely low sperm concentration in
ejaculate, often with poor motility and morphology.

Clinical Situations

•Sperm count < 1 million/mL
•Repeated semen samples showing very few or no
motile sperm
•High sperm DNA fragmentation in ejaculated sperm
•Poor fertilization or embryo development in previous
ART cycles

Rationale for SSR

Testicular sperm may have:

Lower DNA fragmentation
Reduced oxidative damage
Better chromatin integrity
Provides more reliable sperm source for ICSI

Expected Outcomes

•Improved fertilization rates in selected cases
•May improve embryo quality
•Useful when ejaculated sperm repeatedly fails

Preferred Techniques

•TESA
•TESE

Indication 4: Ejaculatory Failure

Definition:

Inability to ejaculate sperm into the semen despite
normal sperm production.

Common Causes

•Spinal cord injury
•Diabetes-related autonomic neuropathy
•Retrograde ejaculation
•Post-surgical nerve damage (pelvic or prostate
surgery)
•Psychogenic anejaculation

Clinical Scenarios

•Absence of sperm in ejaculate
•Sperm detected in post-ejaculatory urine
(retrograde ejaculation)
•Failure of medical or electroejaculation methods

Rationale for SSR

•Sperm production may be normal
•Mechanical failure of ejaculation
prevents sperm delivery
•SSR provides direct access to viable
sperm

Preferred Techniques

•TESA
•TESE
(when non-surgical sperm recovery fails)

Indication 5: Genetic Conditions

Definition:

SSR is indicated in selected genetic disorders where
spermatogenesis is reduced but not completely absent.

Common Genetic Conditions

•Y-chromosome microdeletion

Especially AZFc deletion (may still have residual
spermatogenesis)

•Klinefelter syndrome (47,XXY)

Mosaic or non-mosaic forms

•Congenital bilateral absence of vas deferens (CBAVD)

Commonly associated with CFTR gene mutations

Clinical Importance

•These patients often present with azoospermia
•Spermatogenesis may be:

Severely reduced
Patchy or focal
SSR allows retrieval of sperm from limited areas of production

Rationale for SSR

•Enables use of patient’s own genetic material
•Avoids donor sperm in suitable cases
•Provides opportunity for biological parenthood

Special Considerations

•Mandatory genetic counseling
•Partner screening (especially in CFTR
mutations)
•Risk of transmitting genetic abnormalities
to offspring
•Preimplantation genetic testing (PGT)
may be advised

Indication 6: Failed ART with Ejaculated Sperm

Definition:

Use of SSR in couples with repeated failure of assisted
reproductive techniques despite adequate semen
parameters.

Clinical Scenarios

•Recurrent fertilization failure in IVF/ICSI
•Poor embryo development or arrest
•High sperm DNA fragmentation in ejaculated sperm
•Repeated implantation failure with male factor contribution

Rationale for SSR

•Testicular sperm may have:

Lower DNA fragmentation
Reduced oxidative stress
Better chromatin integrity
Avoids damage acquired during epididymal transit
May improve fertilization and embryo quality

When to Consider

•After ≥2 failed ART cycles
•When high DNA fragmentation index (DFI) is
documented
•When no female factor explains repeated
failure

Preferred Techniques

•TESA
•TESE
(depending on availability of ejaculated
sperm and testicular status)

Cryopreservation After SSR

Definition:

Freezing and storage of surgically retrieved sperm
for future use in assisted reproduction.

Why Cryopreserve SSR Sperm?

•Avoids the need for repeat surgical procedures
•Allows use in multiple ICSI cycles
•Provides backup in case fresh cycle fails
•Especially important in NOA patients where
retrieval may be difficult

Clinical Advantages

•Enables scheduling flexibility between male and
female procedures
•Reduces patient discomfort and surgical risk
•Allows time for genetic testing or counseling
•Cost-effective in long-term management

Technique Selection Based on Indication

The choice of surgical sperm retrieval
technique depends on the underlying cause
of azoospermia and prior clinical findings.

Clinical Condition	Preferred SSR Technique
Obstructive azoospermia (OA)	PESA / MESA
Failed epididymal retrieval	TESA / TESE
Non-obstructive azoospermia (NOA)	micro-TESE
Ejaculatory failure	TESA / TESE
Severe oligozoospermia	TESA / TESE
Genetic conditions (selected cases)	micro-TESE
Previous failed TESE	micro-TESE

Key Take-Home Messages

Surgical sperm retrieval (SSR) is a key
intervention in the management of severe male
factor infertility
Azoospermia must be correctly classified into
obstructive and non-obstructive types before
planning SSR
Proper patient selection and preoperative
evaluation are critical for success
Choice of technique should be indication-based
SSR combined with ICSI enables biological
parenthood in many previously untreatable cases
Genetic counseling is essential in selected
patients

Dr. Rutvij Dalal

He is an award-winning IVF specialist and the founder of Janini IVF in Paschim Vihar, New Delhi. Holding an official super-specialty FNB in Reproductive Medicine and fellowship training from the University of Oxford (UK), he brings over 19 years and 10,000+ IVF cycles of clinical expertise, specializing in male infertility, recurrent IVF failures, and advanced reproductive technology.