Schematic model.

Operative animation, MicroTESE

Microdissection TESE: surgical sperm retrieval in non-obstructive azoospermia

Surgical sperm retrieval for a man with non-obstructive azoospermia who wants to father a child by ICSI.

Each testis is delivered through one midline scrotal incision, opened along its equator between the subtunical vessels like a book, and searched under the operating microscope for the few dilated, opaque tubules that may hold sperm.

Only those are taken and passed to the embryologist. The lessons are the blood supply that the incision must spare, and the plan, made beforehand with the couple and the laboratory, for the day no sperm is found.

Advanced tier FRCS andrology, male infertility and surgical sperm retrieval Interactive 3D
Schematic scene preview: MicroTESE
Preparing the 3D anatomy…

UrOops3D · UroRef · © Nity G

How to use this module. Play through the eight steps, or use Back and Next. Watch the testis open like a book between the vessels, and the screen show the tubules and the laboratory result. The triggers show a haematoma, a vessel taken, no sperm found, and conventional TESE and PESA for comparison.

Click me next Section 2 of 8 Anatomy The structures this operation works between, and the one it must not cross.

The structures in the scene

MicroTESE: how the structures relateThe opened testis under the microscope, and what lies round it. Testicular parenchyma, opened like a book: picked out from the thin ones; only these taken Dilated, opaque seminiferous tubules. Testicular parenchyma, opened like a book: fed by them; the incision runs between Subtunical vessels (danger). Testicular parenchyma, opened like a book: opened along the equator, closed after Tunica albuginea. Testicular parenchyma, opened like a book: behind it, on the hinge; left alone Epididymis (danger). Testicular parenchyma, opened like a book: every piece taken costs testosterone Leydig cells: testosterone (danger). Testicular parenchyma, opened like a book: each sample examined at once Embryology laboratory.Testicular parenchyma,opened like a bookDilated, opaqueseminiferous tubules!Subtunical vesselsTunica albuginea!Epididymis!Leydig cells:testosteroneEmbryologylaboratorypicked out from thethin ones; onlythese takenfed by them; theincision runsbetweenopened along theequator, closedafterbehind it, on thehinge; left aloneevery piece takencosts testosteroneeach sampleexamined at onceTargetDangerLandmarkContext
The opened testis under the microscope, and what lies round it. Schematic, not to scale; relationships only.
  • Seen from in front, with the patient supine, the delivered testis lies on the front of the scrotum with the epididymis behind it and its cord running back up into the wound.
  • The subtunical vessels run transversely round the front and sides under the tunica albuginea.
  • An equatorial incision between them, stopping short of the back, lets the upper and lower halves swing open on the posterior hinge, so that both cut faces of the parenchyma face the microscope.
  • ›Tunica albuginea - the tough white capsule of the testis; it is opened along its equator and closed again with a fine running suture.
  • ›Subtunical vessels - branches of the testicular artery running round the testis just under the tunica albuginea; the incision lies between them.
  • ›Seminiferous tubules - thin and translucent where there is no spermatogenesis; larger and opaque where there is.
  • ›Testicular parenchyma - the tubules and the interstitium, where the Leydig cells make testosterone; what is taken is lost to both.
  • ›Epididymis - behind the testis; full and the site of retrieval in obstruction, left alone in non-obstructive disease.
  • ›Tunica vaginalis - the serous sac round the testis, opened to deliver it and closed on its return.
  • ›Spermatic cord - with the testicular artery, the pampiniform veins and the vas; it runs back into the wound from the delivered testis.
  • ›Scrotal skin, dartos and median raphe - the midline wound on the raphe reaches both testes.
Click me next Section 3 of 8 Steps The operation in order, with the landmark that guards each move.

Operative steps

  1. Work-up, laboratory plan, anaesthesia Azoospermia is confirmed, and the hormonal and genetic work-up, the partner and the ICSI plan are reviewed; the embryology laboratory is ready on the day. Supine, prepared, draped, time-out. Both testes are examined; under a general anaesthetic a spermatic cord block is given on each side for the pain afterwards.
    where it bites: a complete AZFa or AZFb deletion means no sperm will be found: the operation is not offered.
  2. Midline scrotal incision A transverse incision is made across the median raphe of the anterior scrotal wall and carried down through the dartos with the diathermy. One midline wound reaches both testes, so the second side needs no second incision.
    where it bites: the skin and dartos vessels in the wound edges are sealed as they are met.
  3. Testis delivered, tunica vaginalis opened The right testis is pushed up from below and delivered into the wound. Its tunica vaginalis is opened down the front and the testis lies free on the drape, with the epididymis behind it and the cord running back into the wound.
    where it bites: the epididymis and the cord are not handled; a twisted cord on return is a torsion made in theatre.
  4. Equatorial incision, opened like a book The operating microscope is brought in. The subtunical vessels are seen running round the testis under the tunica albuginea, and a wide equatorial incision is made with a microknife in the relatively avascular plane between them. The two halves are opened like a book on a posterior hinge.
    where it bites: the subtunical vessels are the blood supply of the parenchyma: a vessel cut or burnt here devascularises the tissue it feeds.
  5. Tubules searched at high magnification At high magnification every region of both cut faces is searched in turn. Most tubules in non-obstructive azoospermia are thin and translucent; the larger, opaque tubules are picked out from them, because they are the ones most likely to hold sperm.
    where it bites: the reserve is small: the search moves through the tissue rather than taking more of it.
  6. Tubules to the embryologist Only the chosen tubules are dissected free with micro forceps and excised with fine curved scissors, and passed at once to the embryologist, who teases them apart and examines them in culture medium. Here the first sample holds no sperm; the search is extended to other regions, and a second sample is negative as well.
    where it bites: every specimen is labelled and handed over in person: a lost or mislabelled sample cannot be taken again.
  7. The other testis Bleeding points are sealed with the microbipolar, the tunica albuginea is closed with a fine running suture and the right testis is returned. The left testis is delivered through the same wound, opened the same way and searched; it has a focus of dilated tubules, and the laboratory reports sperm.
    where it bites: the second testis is explored only when the first has yielded nothing, and with the same care for its vessels.
  8. Haemostasis, closure, return The tissue is cryopreserved for ICSI. Haemostasis is secured with the microbipolar, the tunica albuginea is closed, and the testis is returned within its tunica vaginalis, which is closed, with the cord untwisted. The dartos and skin are closed, and a dressing and a scrotal support are applied.
    where it bites: a dry field before closure: bleeding inside the tunica albuginea becomes a haematoma that can cost the testis.
Click me next Section 4 of 8 Danger zones Where this operation bites, and why it bites there.
Critical relationship

Danger zones

The spatial relationships the animation is built to make automatic. Before you read each one, ask yourself: at this point in the operation, what is about to go wrong, and what is my first move? The save for each sits in the Complications tab.

  • RiskTesticular artery and intratesticular vessels - the subtunical branches run under the tunica albuginea; the equatorial incision lies between them and bleeding points are sealed point by point.
  • RiskEpididymal tubules - behind the testis; handled only when they are the target, as in obstruction.
  • RiskLimited testicular reserve in non-obstructive disease - only the chosen tubules are taken; every piece of parenchyma removed costs spermatogenesis and testosterone.
  • RiskThe laboratory chain - each sample is labelled, handed over and examined at once; the plan for freezing is agreed before the incision.
Practise it Take me into the scene Opens the animation at a danger moment and asks you to predict the mechanism and your first move before it reveals.
Click me next Section 5 of 8 Complications The save for each one: the first move, the escalation trigger, the op-note line.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

Scrotal haematoma

  • that evening the right hemiscrotum is tense, swollen and bruised; bleeding is a listed complication, from the testis, the tunica or the skin edge.
The save
  1. Examine him: a soft, stable swelling is managed with a support, ice and analgesia, and reviewed. first move
  2. Check the testis is still palpable and the skin is not tense; arrange an ultrasound if the testis cannot be felt.
  3. A tense, expanding or very painful haematoma is a senior review now; it may need exploration, evacuation and haemostasis. escalation trigger
  4. Record the size and progress of the swelling and the plan, and tell him what would bring him back. document

Devascularisation and atrophy

  • a subtunical vessel has been cut or burnt and the parenchyma it fed is pale; testicular atrophy and hypogonadism are listed complications.
The save
  1. Stop: no more tissue is taken from the pale region. Bleeding is stopped with the microbipolar on the bleeding point alone. first move
  2. Keep the rest of the search in the vascular parenchyma, and close the tunica albuginea without tension.
  3. Tell a senior, and agree follow-up of testicular size and of testosterone. escalation trigger
  4. Op note: which vessel was taken, where, and how much tissue was removed. document
  5. Check testosterone afterwards and treat symptomatic hypogonadism; it is a lifelong question for a man with little reserve.

No sperm found

  • both testes have been opened and searched and every sample is negative; the inability to find sperm-laden tubules is a listed outcome of the operation.
The save
  1. Stop: the search is complete when every region has been seen; more tissue would cost testosterone and not find sperm. first move
  2. Close both testes with the same care, and confirm with the laboratory that every sample has been examined.
  3. The consultant tells him and his partner the same day, with the embryologist where possible, and the fertility team is informed. escalation trigger
  4. Op note and laboratory record: regions searched on each side, samples taken and the result of each. document
  5. Counselling: donor sperm, adoption, or no further treatment, when they are ready; a repeat operation is rarely helpful.
Click me next Section 6 of 8 Troubleshooting When the case turns: the problem, then the next move.

Intra-operative troubleshooting

When the case turns: the problem, then the next move.

  • ActionThe cause of azoospermia is not clear - obstruction is likely with normal FSH and normal-sized testes, non-obstructive disease with raised FSH and small testes. The hormonal and genetic work-up comes before surgery.
  • ActionObstructive azoospermia - spermatogenesis is normal: PESA, MESA, TESA or TESE all retrieve sperm, and MESA usually gives enough for several ICSI cycles. Reconstruction is considered when the obstruction can be repaired.
  • ActionConventional TESE or microTESE - conventional TESE takes tissue through small windows without the microscope. In non-obstructive disease the guideline recommends microTESE as the treatment of choice and advises against needle aspiration.
  • ActionBleeding from the cut face - microbipolar on the bleeding point alone; broad diathermy on the parenchyma destroys the tubules being searched.
  • ActionSperm seen in the first sample - the embryologist says how much is enough; the search stops there and the other testis is left alone.
  • ActionInfection - antibiotics at induction, as the chapter does; a red, hot hemiscrotum afterwards is examined for an abscess.
Click me next Section 7 of 8 FRCS viva Say it out loud, then mark yourself against the model answer.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

QA man has azoospermia on two semen samples. How do you decide whether it is obstructive or non-obstructive, and why does it matter?reveal answer
  • I would take a history, including fertility before, infection, surgery such as a hernia repair or vasectomy, and drugs, and examine the testes and both vasa.
  • In obstructive azoospermia the testes are of normal size, the FSH is normal and the epididymis may feel full; absent vasa point to congenital absence, which needs CFTR testing.
  • In non-obstructive azoospermia the testes are often small and soft and the FSH is raised.
  • The EAU guideline asks that it is confirmed on two semen analyses after centrifugation and that the work-up includes hormones, genetics and a scrotal ultrasound.
  • It matters because it decides the operation.
  • In obstruction spermatogenesis is normal, so PESA, MESA, TESA or TESE all retrieve sperm, or the obstruction can be reconstructed.
  • In non-obstructive disease sperm may be found only in small foci, so the retrieval of choice is microdissection TESE, and needle aspiration is not recommended.
Strong pass

Say both

  • Matching the retrieval to the cause: aspiration for obstruction
  • MicroTESE for non-obstructive disease
Examiner note
Matching the retrieval to the cause: aspiration for obstruction, microTESE for non-obstructive disease.
QWhat work-up do you want before you offer him microTESE?reveal answer
  • Hormones first: FSH, LH and total testosterone, which the EAU guideline asks for in every azoospermic man.
  • Then genetics: a karyotype, which finds Klinefelter syndrome, and Y chromosome microdeletion testing.
  • A complete deletion of the AZFa or AZFb region means that no sperm will be found, and the guideline says not to operate.
  • With an AZFc deletion, sperm can be found in 50 to 75 per cent of men, and the couple need genetic counselling because a son would inherit it.
  • I would also want a scrotal ultrasound for a tumour, and the partner assessed by the fertility team, so that the retrieval is timed with a planned ICSI cycle or the tissue is frozen.
  • I would be clear that FSH and testicular size do not reliably predict whether sperm will be found, so I counsel that no sperm is a real possibility.
Strong pass

Say both

  • Naming the AZFa and AZFb deletions as the contraindication
  • Not promising a result from the FSH
Examiner note
Naming the AZFa and AZFb deletions as the contraindication, and not promising a result from the FSH.
QWhy use the microscope? What are the sperm retrieval rates?reveal answer
  • In non-obstructive azoospermia spermatogenesis is often patchy, and the tubules that hold sperm are larger and more opaque than the rest.
  • The microscope lets me find them, take only those, and see the subtunical vessels so that the incision spares them.
  • In the meta-analysis of Bernie and colleagues, from Schlegel's group, microTESE was 1.5 times more likely than conventional TESE to retrieve sperm, and conventional TESE twice as likely as aspiration.
  • The EAU guideline quotes unadjusted rates of 52 per cent for microTESE against 35 per cent for conventional TESE.
  • The larger meta-analysis of Corona and colleagues found an overall rate of 47 per cent with no difference between the two techniques, at 46 per cent each.
  • So the guideline recommends microTESE as the treatment of choice, but only as a weak recommendation, because the evidence is observational.
  • What I would tell a couple is that about half of men have sperm found, and that the microscope takes less tissue.
Strong pass

Say both

  • Quoting both meta-analyses
  • Knowing why the recommendation is weak
Examiner note
Quoting both meta-analyses and knowing why the recommendation is weak.
QHow do you work with the fertility laboratory on the day?reveal answer
  • The plan is agreed before the day: whether the retrieval is timed with the partner's egg collection for fresh ICSI, or the tissue is frozen for a later cycle, and that an embryologist is in theatre or next door.
  • Each sample goes straight from my scissors into culture medium, labelled, and is handed over in person; the embryologist teases it apart and examines it at once and tells me whether sperm are seen.
  • That result decides whether I stop, search further in the same testis, or open the other one, so the search is led by the laboratory.
  • At the end, the samples, their labels and the results are recorded by both of us, and the frozen tissue is stored under the consent the couple have signed.
  • A lost or mislabelled sample is a disaster that cannot be repeated.
Strong pass

Letting the embryologist's result decide when the search stops.

QBoth testes have been searched and no sperm are found. What do you do?reveal answer
  • I would stop.
  • Once every region of both testes has been seen, further tissue is unlikely to help and will cost testosterone in a man with little reserve.
  • I would check with the embryologist that every sample has been examined, close both testes carefully and record what was searched and taken.
  • I, or the consultant, would tell him and his partner the same day, ideally with the embryologist, because they will have been waiting for the result.
  • I would remind them that this was a possibility we discussed beforehand, and offer the options when they are ready: donor sperm, adoption, or no further treatment.
  • I would also arrange a testosterone check later, because hypogonadism is a listed complication, and make sure the fertility team knows the result before any egg collection.
Strong pass

Say both

  • Stopping when the search is complete
  • Planning the conversation before the operation
Examiner note
Stopping when the search is complete, and planning the conversation before the operation.
Click me next Section 8 of 8 Evidence The guidance each of these answers is built on.

Evidence and guidance

Operative Dictations in Urologic Surgery
Armenakas NA, Fracchia JA, Golan R. Microsurgical Testicular Sperm Extraction (MicroTESE). Chapter 40. Wiley, 2019
Followed for the indications, the four essential steps and the template dictation. Indications: non-obstructive azoospermia after assessment of Y chromosomal microdeletions, and failure to find sperm in the epididymis, or complete absence of the vas. The testis is delivered through an anterior scrotal incision, transverse through the anterior wall or the median raphe, after the tunica vaginalis is opened. Under the microscope a transverse incision is made in a relatively avascular area of the tunica albuginea at the midportion of the testis. Sperm-containing tubules are identified by their larger size and opaque colour, dissected and excised, and examined at once; if none is found the procedure is repeated at another location. Variations: percutaneous aspiration may be enough for some, and bilateral exploration may be needed. Haemostasis with microbipolar cautery, closure of the tunica albuginea, the testis returned within the tunica vaginalis, which is closed, and dartos and skin closure, a dressing and a support. Complications: bleeding, infection, inability to find sperm-laden tubules, epididymal or testicular injury, testicular atrophy and hypogonadism. General practice, not from the chapter: the median raphe chosen over a hemiscrotal incision, a general anaesthetic with a cord block, the right side first, the opening of the testis like a book on a posterior hinge, and every first, escalate and document step.
Open guideline
EAU
European Association of Urology. Guidelines on Sexual and Reproductive Health, chapter on male infertility, read online 19 October 2026
Hormonal evaluation including total testosterone, FSH and LH in all azoospermic men; karyotype and genetic counselling; Y chromosome microdeletion testing; no testicular sperm extraction with complete deletions of the AZFa and AZFb regions; testicular sperm found in 50 to 75 per cent of men with AZFc deletions. Non-obstructive azoospermia confirmed on two semen analyses after centrifugation, with a full assessment including a scrotal ultrasound. TESE is about two times more likely than TESA to succeed, and TESA is no longer recommended. Unadjusted retrieval rates of 35 per cent for conventional TESE and 52 per cent for microTESE in a meta-analysis of case-control studies; an overall rate of 47 per cent in another, with 46 per cent for each technique. Use microdissection TESE as the treatment of choice in non-obstructive azoospermia (weak). Preoperative variables do not reliably predict retrieval. In obstruction, MESA, PESA, TESA or TESE, and one MESA usually gives sperm for several ICSI cycles.
Open guideline
Fertility and Sterility
Bernie AM, Mata DA, Ramasamy R, Schlegel PN. Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis. Fertil Steril 2015;104:1099-1103
Abstract read 19 October 2026. Fifteen studies, 1,890 men with non-obstructive azoospermia. In direct comparison microTESE was 1.5 times more likely than conventional TESE to retrieve sperm, and conventional TESE 2.0 times more likely than TESA. Pregnancy outcomes could not be assessed because of inconsistent reporting.
Open guideline
Human Reproduction Update
Corona G, Minhas S, Giwercman A, et al. Sperm recovery and ICSI outcomes in men with non-obstructive azoospermia: a systematic review and meta-analysis. Hum Reprod Update 2019;25:733-757
Abstract read 19 October 2026. 117 studies, 21,404 men. Overall sperm retrieval rate per procedure 47 per cent, with no difference between conventional TESE and microTESE (46 per cent each). Retrieval rose with testis volume and was independent of age and hormones. Live birth rate up to 28 per cent per ICSI cycle. A properly powered randomised trial is needed.
Open guideline

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topic Andrology. Not a workplace-based assessment and not evidence of competence.

Two minutes

Close the lap: recall it before you leave.

Say it aloud, then reveal. Reading is not remembering.

  1. 01 The relationship Say the critical spatial relationship out loud, then reveal. reveal
    Memory frame

    Seen from in front, with the patient supine, the delivered testis lies on the front of the scrotum with the epididymis behind it and its cord running back up into the wound.

    Why?
    The subtunical vessels run transversely round the front and sides under the tunica albuginea. An equatorial incision between them, stopping short of the back, lets the upper and lower halves swing open on the posterior hinge, so that both cut faces of the parenchyma face the microscope.
  2. 02 The first move Scrotal haematoma. Your first move? reveal
    First move

    Examine him: a soft, stable swelling is managed with a support, ice and analgesia, and reviewed.

  3. 03 The escalation trigger Scrotal haematoma. What makes you call for help? reveal
    Escalate when

    A tense, expanding or very painful haematoma is a senior review now; it may need exploration, evacuation and haemostasis.

  4. 04 The discriminator What turns a pass into a strong pass? reveal
    Strong pass

    Say both

    • Matching the retrieval to the cause: aspiration for obstruction
    • MicroTESE for non-obstructive disease
    Examiner note
    Matching the retrieval to the cause: aspiration for obstruction, microTESE for non-obstructive disease.
  5. 05 The pitfall Where does this operation bite first? reveal
    Pitfall

    Testicular artery and intratesticular vessels

    Why?
    the subtunical branches run under the tunica albuginea; the equatorial incision lies between them and bleeding points are sealed point by point.

Revision practice with self-marked answers, not an assessment of clinical competence. Kept in this browser only; it does not sync between devices.