In severe cases of male infertility such as an ejaculation, the absence of sperm on a semen analysis may be due to azoospermia, cause from congenital bilateral absence of the vas deferens, vasectomy or no viable sperm after ejaculation, death of all sperm ejaculated or testicular inflammation due to the mumps virus or other causes. To overcome severe male infertile problem there are treatment options depending on the sperm source available and patient preference such as the following:

– Percutaneous Epididymal Sperm Aspiration (PESA): This involves the same needle and syringe technique but the needle is placed directly into the epididymis.
– Microsurgical Epiddymal Sperm Aspiration (MESA): This is an open surgical sperm retrieval procedure that uses an operating microscopy to locate the tubules of the epididymis precisely, so that large numbers of sperm can be extracted.
– Testicular Sperm Aspiration (TESA): This involves placing a needle attached to a syringe through the skin of the scrotum and simply sucking out the fluid inside the testicle
– Testicular Sperm Extraction (TESE): This is an open surgical biopsy technique to remove a few testicular tissues and extract to find the sperm.