Reasons for not completing postvasectomy semen analysis

METHODS

A mixed-methods design was used consisting predominantly of qualitative data sampling. Before starting data collection, this project was reviewed by the Biomedical Research Ethics Board at the University of Saskatchewan and received an exemption from a research ethics review. Our group conducted a retrospective chart review of men who had undergone vasectomy since 2009; this was followed by telephone interviews. We used 2 sources of patient information for this study, with 1 cohort from an academic family medicine clinic (West Winds Primary Health Centre [WWPHC]) and 1 cohort from a fee-for-service community clinic (City Centre Family Physicians [CCFP]). First, we determined the number of men who had undergone vasectomy, generating a list of patients from both clinics by searching their respective electronic medical record systems using the billing code for the vasectomy procedure. Once we had the total number of patients who had undergone vasectomies, we had to use different methods depending on the clinic to determine if PVSA results were on file because each clinic used a different electronic medical record system. For the academic family medicine clinic, we reviewed each chart manually to determine whether there was a PVSA laboratory result on file. For the community clinic, we were able to search the laboratory results of the patients generated by the vasectomy billing code with the key words semen, post-vas, post vas, and vasectomy to generate the list of PVSA results on file. In order to confirm that these search parameters were correct, the first 200 charts were reviewed in the community clinic to ensure these key words corresponded with the correct laboratory results.

Next, we contacted, by telephone, patients who had undergone vasectomies but who did not have PVSA results on file. Each call adhered to a predetermined telephone script to ensure patient confidentiality, consent, and willingness to participate in the study. Once verbal consent was obtained, patients were asked if they were comfortable disclosing the reason for not completing their 3-month PVSA. Further, we inquired about whether the patients recalled being counseled about the importance of completing their PVSA test. Each patient was also asked if they were interested in pursuing a PVSA at this time after discussing the benefits of the PVSA and the risks of noncompliance. At the end of the conversation, participants were instructed that they could withdraw their response in the future by contacting the researchers and were asked to indicate if they wished to receive a copy of the study results.

We placed telephone calls to every postvasectomy patient from WWPHC without a PVSA result on file. However, owing to the large patient cohort without PVSA results from CCFP, we only placed calls to every third patient on an alphabetized list. This decision was made based on limited time and resources to make more than 1000 telephone calls and the fact that saturation was reached with the sample contacted.

The data were entered into a Microsoft Excel spreadsheet. We did not require the use of any higher-order statistics to analyze the data; compliance rates and responses were calculated using simple percentages and grouped responses. We were then able to report compliance and noncompliance rates for both clinics. Finally, the subjective reasons for not completing PVSA were grouped into several broad categories based on patients’ individual responses using an inductive thematic analysis approach. These categories were determined based on similar themes that were uncovered during our discussions with patients.

FINDINGS

Our chart review identified a total of 1972 patients who had undergone vasectomy (160 from WWPHC and 1812 from CCFP). Of those, 779 patients had PVSA results on file (83 from WWPHC and 696 from CCFP). Of the combined totals, 1193 patients did not have PVSA results on file (77 from WWPHC and 1116 from CCFP). Telephone calls were made to 454 purposefully selected participants, using the semistructured interview script. From those calls, 106 patients answered and 99 agreed to participate (21 from WWPHC and 78 from CCFP) (Table 1).

There was a combined compliance rate for PVSA of 39.5% and a substantial combined noncompliance rate of 60.5%. However, it is important to note that these rates differed between the 2 clinics when examined individually. The WWPHC was found to have a lower noncompliance rate of 48.1%, and CCFP alone had a noncompliance rate of 61.6%. The difference between the compliance rates at the academic clinic versus the community clinic was statistically significant. (A 2-tailed z score was calculated; z = −3.3396; P = .00084. The result is significant at P < .01 with a 99% CI.)

The men who had no PVSA results on file gave several consistent responses during our telephone discussions to explain their noncompliance (Table 2). We spoke with a total of 99 men and combined the responses from the 2 clinics. It is important to note that the participants were not limited to a single response; if they gave more than 1 answer, each answer was recorded in the total. A total of 22.2% of men that stated they were confident in the procedure and the physician performing the vasectomy, and therefore did not feel the need for confirmatory testing. Next, 15.2% of men felt inconvenienced by the testing process itself, including hours of operation for the andrology laboratory, its distance from their home, and the need to transport a specimen or provide one in the facility. A total of 28.3% of patients felt that they were too busy to follow through with testing, owing to family, work, or other personal commitments. A total of 13.1% of men simply stated that they were not going to have the test done or admitted that they had procrastinated and put it off for so long that they no longer wished to follow through. Only 6.1% of patients felt too embarrassed by the testing process itself to complete the PVSA, particularly when it came to providing a sample. Additionally, 14.1% of men claimed to have had the test completed at some point, presumably with the results having been forwarded to another health care provider, resulting in no record of their PVSA on file (Figure 1). Furthermore, 3.0% of patients informed us that their vasectomies were less than 3 months ago and that, therefore, PVSA was not yet due. Some patients (10.1%) also stated that they simply forgot to complete the PVSA. Finally, 5.1% of patients gave unique responses that did not fit into any of the aforementioned categories.

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Figure 1.

Participants’ self-reported reasons for not completing PVSA

CCFP—City Centre Family Physicians, PVSA—postvasectomy semen analysis, WWPHC—West Winds Primary Health Centre.

There are some additional results worth mentioning surrounding PVSA counseling done after the procedure and over the telephone when we contacted these men (Table 3). A total of 97.0% of men recalled being counseled about the importance of having PVSA completed in order to confirm sterility. After our discussions with the men who had not completed PVSA, 24.2% expressed that they were now interested in pursuing PVSA, and 7.1% indicated they would now consider the possibility of PVSA testing in the future. Those who expressed interest in PVSA were then referred back to their family doctors with instructions on how to get testing done, and those who would consider PVSA in the future were encouraged to discuss this further with their family doctors.

DISCUSSION

While we identified high noncompliance rates, consistent with previous studies, our noncompliance rates differed somewhat from those that have been reported in the literature. We also found a difference between the noncompliance rates from the 2 clinics that we examined. Noncompliance rates have typically been 30% or higher^6–8 in previous studies, with a recent Canadian study from Dalhousie University in Halifax, NS,¹² reporting a noncompliance rate of 47.9%. The noncompliance rate at WWPHC (48.1%) appears to be consistent with rates found in previous studies. However, CCFP had a higher noncompliance rate of 61.6%. The reason for the difference between these 2 clinics is unclear; however, there are several factors that might be contributing to the higher noncompliance rates at CCFP. The WWPHC is an academic practice with resident physicians and longer appointment times. Attending physicians at WWPHC review resident notes and counseling procedures to ensure PVSA counseling is emphasized. The CCFP also performs a higher number of vasectomies overall, with a greater number of external consultations for which follow-up is more challenging (no regular source of updated contact information, no routine follow-up, etc). It is also important to note that both clinics routinely provide postprocedure handouts with instructions for PVSA testing.

Additional reasons for higher noncompliance rates in this study might include the fact that some patients indicated that they had completed the PVSA despite not having a record of this on file. A total of 17 patients in the study reported completing the PVSA or stated that it was not yet due, but this number could potentially be higher if more men were successfully contacted. In terms of the categories of responses we received regarding PVSA noncompliance, responses were similar between WWPHC and CCFP. There were some slight differences between the clinics, but 3 categories accounted for most of the responses. These categories included patients feeling they were too busy (28.3%), men feeling confident in the procedure or physician (22.2%), and men feeling inconvenienced by the testing process (15.2%). If compliance rates in Saskatoon are to improve, counseling regarding these specific responses might help increase compliance. This counseling could potentially take place before or immediately after the procedure, or in the form of a follow-up visit or reminder (telephone call, mailed letter, e-mail, text message, etc). It might be helpful for the physician to stress that despite a busy lifestyle, the PVSA is still paramount to confirming sterility and that unexpected pregnancies are more time consuming than an appointment at the andrology laboratory. Physicians should also stress that despite confidence in the procedure, vasectomy failure is still a possibility.