Comparison of embryological and clinical outcomes of ICSI cycles using ejaculated versus testicular sperm (TESA/mTESE) in men with cryptozoospermia: A retrospective cohort study

Objective: To compare the embryological and clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles using ejaculated versus testicular sperm (TESA/mTESE) in men with cryptozoospermia. Materials and Methods: This retrospective cohort study included 127 ICSI cycles performed in couples with male cryptozoospermia at the Acıbadem Maslak Hospital Assisted Reproductive Technology Center between 2017 and 2026. Cycles were grouped according to sperm source as ejaculated (n=58) or testicular (n=69; mTESE, n=51; TESA, n=18). The primary outcome was the pregnancy rate per embryo transfer. Multivariable logistic regression was used to adjust for confounders. Results: Baseline characteristics were similar, except for a higher number of previous IVF attempts in the testicular sperm group (p=0.032) and a more frequent history of miscarriage in the ejaculated sperm group (15.5% vs. 4.5%, p=0.037). The testicular sperm group had more day 5 blastocysts (median 5 vs. 3, p=0.004) and a higher blastocyst formation rate (57.2% vs. 34.3%, p<0.001), but also more grade 3 blastocysts (p<0.001). Per embryo transfer, pregnancy (80.0% vs. 54.5%, p=0.006) and clinical pregnancy rates (78.0% vs. 47.3%, p=0.001) were higher in the ejaculated sperm group, whereas live birth rates were similar (48.0% vs. 45.5%, p=0.794). After adjustment for female age, previous IVF attempts, embryo stage at transfer and embryo quality, sperm source was not independently associated with pregnancy (adjusted odds ratio: 1.94, 95% confidence interval: 0.71-5.26, p=0.195); blastocyst-stage transfer and grade 1 embryo quality were the independent predictors. Conclusion: In men with cryptozoospermia, testicular sperm increased blastocyst yield but did not improve pregnancy or live birth rates compared with ejaculated sperm. When ejaculated spermatozoa are available, routine surgical sperm retrieval does not appear to provide a clinical advantage.