The use of an operating microscope for testicular sperm extraction procedures increases the likelihood of finding sperm. The optical magnification is helpful in that it aids the visualization of the tubules. In this procedure, an incision is made in the scrotum, and the testis is delivered from it. An equatorial polar incision (at a right angle to the long axis of the testis) is made, and the testis is completely opened, exposing all the tubules. All of the tubules can be surveyed in this fashion. The largest and most opaque tubules are identified, because these are the ones responsible for spermatogenesis, and sperm is most likely to be found there. They are removed and passed off to the embryologist, who determines whether sperm is present.

In cases where simple open TESE would fail, the MicroTESE (Microsurgical Testicular Sperm Extraction) has been successful. The procedure has been helpful in cases of hypospermatogenesis, spermatogenic arrest, and sertoli cell only. Even in cases where the FSH is very high, MicroTESE has been used to find sperm. While the cost of the procedure is higher than standard TESE, it yields more success and less tissue is removed than at a standard TESE.