Male Infertility and IVF: Complete Guide to ICSI and TESE for Oligospermia, Asthenospermia, and Azoospermia

Key Takeaways: Male factor infertility accounts for approximately 40-50% of all infertility cases — but it does not mean parenthood is impossible. AddBaby Medical & Fertility Center uses ICSI (intracytoplasmic sperm injection) and TESE/TESA (surgical sperm retrieval) to help men with severe oligospermia, asthenospermia, and even azoospermia achieve biological fatherhood. This guide covers diagnosis, treatment protocols, success rates, and costs.

Quick Reference Summary

Item	Details
Who it's for	Men with oligospermia, asthenospermia, teratospermia, or azoospermia and their partners
Core technologies	ICSI single-sperm injection; TESE/TESA surgical sperm retrieval
ICSI additional cost	~$1,500-2,500 USD above standard IVF
TESE procedure cost	Obstructive: ~$750-1,500 USD; Micro-TESE: ~$2,200-4,500 USD
Success rate reference	ICSI fertilization rate 70-80%; TESE sperm retrieval 50-95%

Classification and WHO Diagnostic Criteria for Male Infertility

Based on the World Health Organization's 2021 semen analysis reference values, male infertility is classified into several main categories:

Semen Parameter Abnormality Classifications

Oligospermia (Low Sperm Count)

• Mild oligospermia: sperm concentration 5-16 x 10⁶/mL
• Moderate oligospermia: 1-5 x 10⁶/mL
• Severe oligospermia: <1 x 10⁶/mL
• Cryptozoospermia: only rare sperm found after centrifugation

Asthenospermia (Poor Sperm Motility)

• WHO criterion: Progressive motility (PR grade) <42%
• Or total motility (PR+NP) <50%

Teratospermia (Abnormal Sperm Morphology)

• WHO criterion: Normal morphology <4% (Kruger strict criteria)
• Common abnormalities: head defects (macrocephaly, microcephaly, duplicated head), neck/midpiece defects, tail defects

Azoospermia (No Sperm)

• Obstructive Azoospermia (OA): testicles produce sperm normally, but the ductal system is blocked
  • Common causes: vasectomy, congenital bilateral absence of vas deferens (CBAVD), post-infectious epididymal obstruction
• Non-Obstructive Azoospermia (NOA): impaired testicular spermatogenesis — sperm production is reduced or absent
  • Common causes: Klinefelter syndrome (47,XXY), Y chromosome microdeletions, cryptorchidism, mumps orchitis

Sperm DNA Fragmentation Index (DFI)

The DNA fragmentation index is a critically important but frequently overlooked test:

• Normal: DFI ≤15%
• Mildly elevated: 15-25% (may impair embryo development)
• Moderately elevated: 25-40% (significantly reduces implantation and live birth rates)
• Severely elevated: >40% (donor sperm should be considered)

High DFI is closely associated with recurrent implantation failure and recurrent miscarriage. All male infertility patients are strongly advised to undergo DFI testing.

ICSI: Intracytoplasmic Sperm Injection — In Depth

What Is ICSI?

ICSI (Intracytoplasmic Sperm Injection) is a micromanipulation procedure in which an embryologist uses an ultra-fine glass needle (inner diameter ~5-7 micrometers) under high-powered microscopy to select a single morphologically normal, motile sperm and directly inject it into the cytoplasm of a mature egg.

Unlike conventional IVF — where large numbers of sperm are co-incubated with eggs and fertilization relies on natural sperm penetration — ICSI bypasses the natural penetration step entirely, requiring only a single viable sperm per egg.

When ICSI Is Indicated

ICSI is the preferred or recommended approach in the following situations:

• Moderate-to-severe oligospermia (sperm concentration <5 x 10⁶/mL)
• Severe asthenospermia (progressive motility <20%)
• Severe teratospermia (normal morphology <1%)
• After TESA/TESE surgical sperm retrieval (obstructive or non-obstructive azoospermia)
• Previous conventional IVF with poor or total fertilization failure
• Use of cryopreserved-thawed sperm
• Elevated sperm DNA fragmentation (DFI >25%)
• Recurrent IVF implantation failures

ICSI Fertilization and Success Rates

Outcome Metric	Data Range
Normal fertilization rate (2PN)	70-80%
Good-quality embryo rate	50-65%
Blastocyst development rate	40-55%
Clinical pregnancy rate (under 35)	50-65% per transfer cycle
Live birth rate (under 35)	40-55% per transfer cycle

ICSI Costs

At AddBaby's partner centers in Thailand, ICSI adds approximately $1,500-2,500 USD to the cost of a standard IVF cycle. In many Thailand premium reproductive centers, ICSI has become standard practice and is often included within the baseline IVF package.

For full IVF-ICSI package pricing details, visit AddBaby's service page.

TESE/TESA Surgical Sperm Retrieval: Treatment for Azoospermia

Sperm Retrieval for Obstructive Azoospermia (OA)

When azoospermia is caused by ductal blockage (OA), sperm production in the testes is typically normal, and retrieval is relatively straightforward:

TESA (Testicular Sperm Aspiration)

• Procedure: Fine needle inserted into the testis under local anesthesia to aspirate sperm
• Best for: Obstructive azoospermia — first-line approach
• Invasiveness: Minimal (comparable to a blood draw)
• Sperm retrieval success rate: Over 95% for obstructive azoospermia
• Yield: Typically sufficient for same-cycle IVF-ICSI use

PESA (Percutaneous Epididymal Sperm Aspiration)

• Procedure: Aspiration from the epididymis (the sperm storage organ adjacent to the testis)
• Best for: Epididymal obstruction causing azoospermia
• Advantage: Sperm motility is often superior to TESA-retrieved sperm

Microsurgical TESE (Micro-TESE)

• Procedure: Testis opened under operating microscope; seminiferous tubules are microscopically examined to identify focal spermatogenesis regions
• Best for: Salvage when conventional TESA/PESA fails in OA patients
• Invasiveness: More significant — requires general anesthesia
• Recovery: Approximately 1-2 weeks

Sperm Retrieval for Non-Obstructive Azoospermia (NOA)

NOA is the more challenging scenario. Testicular spermatogenesis itself is impaired, but some NOA patients retain isolated focal areas of sperm production (focal spermatogenesis) that can be identified microscopically.

Micro-TESE is the standard treatment for NOA

Underlying Cause	Micro-TESE Success Rate
Klinefelter syndrome (47,XXY)	40-60%
Y chromosome AZFc microdeletion	50-70%
Y chromosome AZFa/b complete deletion	Very low (<5%) — surgery usually not recommended
Post-cryptorchidism (orchidopexy)	40-60%
Idiopathic NOA	40-55%
Post-mumps orchitis	30-50%

Critical note: Y chromosome microdeletion testing is mandatory before Micro-TESE. Men with complete AZFa or AZFb deletions have sperm retrieval rates below 5%, and this must be communicated clearly before surgery is considered.

Coordinating TESE with IVF Timing

The timing coordination between male sperm retrieval and female egg retrieval is critical:

Option 1: Fresh TESE Synchronized with Egg Retrieval

• Both procedures performed on the same day
• Advantage: Fresh sperm with optimal motility
• Risk: If sperm retrieval fails, the entire cycle may be compromised (backup frozen sperm reduces this risk)

Option 2: Freeze-First Strategy (Recommended for NOA)

• TESE performed and sperm cryopreserved in advance
• Female IVF cycle proceeds using thawed sperm
• Advantage: Eliminates catastrophic cycle failure if retrieval is challenging
• AddBaby recommendation: This is the preferred approach for all NOA patients

Sperm DNA Fragmentation and Treatment Decision-Making

High DFI (sperm DNA fragmentation) is an important factor affecting IVF outcomes that is frequently undertreated:

Clinical Significance of DFI Testing

DFI Level	Impact on IVF	Recommendation
<15%	No significant impact	Standard protocol
15-25%	Mild impact on embryo development	Consider ICSI
25-40%	Significant impact on implantation and live birth rates	ICSI + epididymal/testicular sperm
>40%	Severe impact, high miscarriage rate	Consider donor sperm or comprehensive evaluation

Interventions to Reduce DFI

Before surgical sperm retrieval, the following may effectively reduce sperm DNA damage:

• Antioxidant therapy: Vitamin C, Vitamin E, Coenzyme Q10, zinc, folate (3-6 months of treatment)
• Optimal abstinence interval: 48-72 hours (excessively long abstinence paradoxically increases DFI)
• Lifestyle modification: Quit smoking, limit alcohol, avoid high-temperature environments (sauna, hot baths)
• Epididymal/testicular sperm: DNA fragmentation in epididymal and testicular sperm is typically significantly lower than in ejaculated sperm

When Is Donor Sperm Recommended?

While the majority of male infertility patients can achieve biological parenthood through ICSI and TESE, the following situations may warrant considering donor sperm options:

1. Complete failure of NOA Micro-TESE (no sperm found across multiple surgical attempts)
2. Complete Y chromosome AZFa or AZFb deletion (retrieval success rate <5%)
3. DFI >40% with no response to conservative treatment
4. Severe hereditary genetic diseases (near-100% transmission probability to offspring)
5. Male partner's refusal of surgery or medical contraindications

Choosing donor sperm is a significant decision involving emotional and ethical dimensions. AddBaby's fertility counselors provide comprehensive psychological support to help couples make the choice that is right for them, accompanying them through every step of the decision and treatment process.

Complete Treatment Pathway

Step 1: Comprehensive Male Infertility Workup

• Semen analysis (at least 2 tests, 1 month apart)
• Sperm DNA fragmentation index (DFI) testing
• Reproductive hormone panel (FSH, LH, testosterone, prolactin, estradiol, AMH)
• Karyotype analysis (46,XY or abnormal)
• Y chromosome microdeletion testing (mandatory for azoospermia)
• Reproductive tract ultrasound (testes, epididymis, prostate)

Step 2: Treatment Protocol Determination

Based on evaluation results, the reproductive specialist tailors a personalized protocol:

• Mild oligospermia/asthenospermia → Conventional IVF or ICSI
• Moderate-to-severe oligospermia/asthenospermia → ICSI
• Obstructive azoospermia → TESA/PESA + ICSI
• Non-obstructive azoospermia → Micro-TESE + ICSI, or donor sperm consideration

Step 3: Coordination of Female Stimulation and Male Retrieval

• Synchronized (fresh protocol) or separate (freeze-first protocol)

Step 4: Laboratory Operations

• ICSI fertilization: embryologist performs single-sperm injection
• Embryo culture: in vitro development to Day 3 (cleavage stage) or Day 5-6 (blastocyst)
• Embryo biopsy: if PGT-A/PGD genetic testing is indicated, performed at this stage

Step 5: Embryo Transfer

• Fresh or frozen embryo transfer (FET)
• Serum hCG blood test 14 days post-transfer to confirm pregnancy

For detailed information on the complete IVF process, visit AddBaby's IVF-ICSI service page, or contact our male infertility specialists directly for professional consultation.

Frequently Asked Questions

Q1: Does ICSI have a higher success rate than conventional IVF?

A: This is a common misconception. ICSI's advantage over conventional IVF applies specifically to the fertilization rate — by physically injecting sperm, ICSI bypasses the natural penetration step, producing significantly higher fertilization rates when sperm quality is poor. However, once fertilization is achieved, embryo development rates, implantation rates, and clinical pregnancy rates are comparable between ICSI and conventional IVF. For couples with normal semen parameters, ultimate live birth rates are similar between the two approaches. ICSI is primarily a tool to overcome fertilization barriers — not a universal method to boost overall IVF success rates.

Q2: Will poor sperm quality be inherited by the child?

A: In some cases, yes — it depends on the underlying cause of infertility. Key scenarios: (1) Chromosomal abnormalities (e.g., Klinefelter syndrome 47,XXY): sons have a meaningful probability of inheritance; (2) Y chromosome microdeletions: sons born via ICSI will almost certainly inherit the father's Y chromosome deletion and may face infertility themselves; (3) CBAVD (congenital bilateral absence of vas deferens): typically associated with CFTR gene mutations with hereditary implications; (4) Functional causes (varicocele, infection, lifestyle): these do not carry genetic hereditary risk to offspring. For cases with suspected genetic etiology, AddBaby recommends PGT-A/PGD genetic testing (preimplantation genetic testing) to screen for chromosomally normal embryos before transfer, preventing transmission of genetic conditions. Learn more at AddBaby's IVF-PGD genetic screening service.

Q3: Does azoospermia always mean needing donor sperm?

A: Absolutely not. Approximately 50-95% of azoospermic men (depending on the underlying cause) can have sperm successfully retrieved through TESA or Micro-TESE to achieve biological parenthood. Obstructive azoospermia has particularly high retrieval success (>95%). Non-obstructive azoospermia has lower success rates (40-70%), but still provides a meaningful proportion of patients with viable sperm. Before deciding to forgo biological parenthood through donor sperm, a comprehensive evaluation is strongly recommended — including at least one Micro-TESE attempt at an experienced reproductive center. AddBaby's Thailand partner centers have extensive NOA Micro-TESE expertise. Reach out to us to discuss your specific situation.

Q4: Does TESE surgery affect testicular function?

A: Technically, any testicular surgery carries some potential for localized tissue effects, but a properly performed TESA (fine-needle aspiration) has minimal impact on testicular function. Micro-TESE, due to its greater surgical scope, carries a small risk of modest testosterone level decline, but most patients recover within 6-12 months. Compared with the potential reproductive benefit, this risk is generally acceptable. Choosing an experienced urologist/reproductive surgeon and following rigorous surgical protocols minimizes these risks significantly.

Conclusion

Male infertility does not equal inability to father children. Modern assisted reproductive technology — particularly the combination of ICSI and TESE — has opened a path to parenthood for the vast majority of men with fertility challenges:

• Oligospermia / asthenospermia / teratospermia → ICSI is the standard approach, with 70-80% fertilization rates
• Obstructive azoospermia → TESA sperm retrieval success >95%, combined with ICSI for parenthood
• Non-obstructive azoospermia → Micro-TESE gives 40-70% of patients a viable opportunity
• High DFI → Epididymal/testicular sperm + ICSI + PGT-A when indicated

AddBaby Medical & Fertility Center's team of experienced andrologists and reproductive specialists in Thailand provides comprehensive solutions from semen analysis to embryo transfer. If you or your partner are dealing with male infertility, we welcome you to contact our fertility consultants for a personalized professional assessment and individualized treatment plan. You can also explore our fertility guarantee programs to proceed through every step of treatment with confidence.

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This article has been reviewed by the AddBaby Medical & Fertility Center medical team. Content is for informational purposes only and does not constitute medical advice. Please consult a qualified medical professional for fertility-related concerns. Last updated: February 2026