The technical procedure for PESA involves the insertion of a needle attached to a syringe through the scrotal skin into the epididymis (Pic 1). Originally, the use of a larger butterfly needle was described. Currently, most experts use a fine needle (26 gauge) attached to a tuberculin syringe containing sperm washing medium. After creating negative pressure by pulling the syringe plunger, the tip of the needle is gently and slowly moved in and out inside the epididymis until fluid is aspirated. If motile sperm are not obtained, PESA may be repeated at a different site (from the cauda to caput epididymis) until an adequate number of motile sperm is retrieved. These aspirations are usually performed in the corpus epididymis and then in the caput epididymis if needed, as aspirates from the cauda are often rich in poor-quality senescent spermatozoa, debris and macrophages. Because PESA is a blind procedure, multiple attempts may be needed before high-quality sperm are found. If PESA fails to enable the retrieval of motile sperm, testicular sperm retrieval can be attempted during the same operation.
Craft and Shrivastav, in 1994, first described the use of the percutaneous approach to retrieve sperm from the epididymis. Percutaneous retrievals are usually undertaken under local anesthesia only or in association with intravenous sedation. Percutaneous sperm retrieval can be either diagnostic or therapeutic. In the former, it is used to confirm the presence of viable spermatozoa prior to ICSI. In the latter, it is carried out at the same day of oocyte retrieval or at the day before.

PESA is fast and low cost sperm retrieval technique. The mainly advantages of PESA are minimal morbidity, repeatable, no microsurgical experstise required, few instruments and material and no open surgical exploration.
Other advantages of PESA in relation to MESA are minimal discomfort for the patient, and lesser
complication rate when compared to open surgery. On the contrary few sperm are retrieved and therefore, limited number of sperm can be cryopreserved.

Percutaneous Surgical Sperm Retrieval procedures can result fibrosis and obstruction at the aspiration site or risk of hematoma/spermatocele.

For patients with obstructive azoospermia is PESA simply and low cost procedure with few motile sperm retriever with limited number of sperm for cryopreservation and hereby is bounded count for use in multiple ICSI cycles to yield optimal reproductive outcomes.

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