PVSA: It’s Complicated

Good information for all practitioners! We have highlighted some of the many comments about Post Vasectomy Semen Analysis, as the topic is one that is addressed frequently, but which has many variables, from whether the sample is fresh or mailed, to how soon after the vasectomy it can be performed. Here are just a few insights doctors have shared. 

A UK perspective on post vasectomy semen analysis

Martin  Kittel, Thames Valley Vasectomy Services, Bourne End, UK

Post vasectomy semen analysis, or PVSA, remains one of the most discussed and least straightforward aspects of vasectomy care. This may come as no surprise in a healthcare system that manages to combine world class clinical expertise with a fondness for paperwork, process, and the occasional administrative maze.

The UK system achieves remarkable things on limited resources, but it is not always elegant, streamlined, or simple. PVSA sits squarely in that reality. Despite frequent debate within professional networks like the ASPC and also and during WVD’s recent 24 hour broadcast, there is still no universally agreed best approach. The complexity lies not only in biology, but also in economics, patient behaviour, and how healthcare systems behave when they meet a small plastic pot.

Practice setting

Thames Valley Vasectomy Services, my organisation, work in both a governmental and a private setting in the UK. We provide vasectomy services under some NHS and armed forces government contracts as well as in private practice, and we offer PVSA to both NHS and private patients.

Is PVSA required?

PVSA is required under the NHS standard contract and the UK National Vasectomy Service Standard. As with many things in medicine, however, requirement does not equal enforcement. Ultimately, it remains the patient’s choice whether to adhere, even when the recommendation is very clear.

Should PVSA be optional?

This is where things become interesting and complicated. The honest answer is that it depends.

In the UK, the commonly quoted vasectomy failure rate lies somewhere between 1 in 100 and 1 in 125 when using the Marie Stopes method. This is uncomfortably high, although that is a separate discussion for another day.

If we instead imagine a failure rate of 1 in 500 or even 1 in 1000, the med economical picture starts to look rather different. A PVSA test costs approximately 50 dollars. At a failure rate of 1 in 100, the cost to detect one failure is around 5000 to 6000 dollars. At 1 in 500, one undetected failure represents a cost of 25,000 dollars. At 1 in 1000, it rises to 50,000 dollars.

These are, of course, in vitro calculations. Not every man with persistent sperm will cause a pregnancy. Sometimes sperm counts are very low. Sometimes the female partner is older and approaching menopause. Sometimes relationships end. Biology, as ever, has a habit of ignoring spreadsheets.

With current guidance in place, it is difficult to move away from a standardised approach. That said, one could reasonably argue for shared decision making if a patient wishes to save the cost. For NHS patients, the test is government funded and free at the point of use, which dramatically increases uptake. This mirrors the broader observation that men are roughly ten times more likely to choose vasectomy when it is free.

Compliance and adherence

The TVVS PVSA adherence rate is approximately 70 percent, which is exactly the national UK average. When we previously worked with a laboratory that had access difficulties, adherence fell as low as 35 percent.

Interestingly, simply making testing easier does not reliably improve compliance. The only intervention that may help is providing the test kit at the time of the vasectomy itself. This reduces the number of men who later discover that their kit has vanished into a drawer, a garage, or a parallel universe, and cannot quite bring themselves to contact the clinic for another one.

Laboratory reliability

Laboratory access is currently one of the biggest challenges for PVSA in the UK. The bureaucracy surrounding semen analysis has become impressively complex, with layers of regulation and administrative oversight that might suggest semen samples are being prepared for space travel rather than microscopy.

I have personally tried to persuade a large private national provider to take on semen analysis services, but at current rates and under the existing regulatory framework, the economics simply did not work for them. As a result, the number of accredited laboratories has fallen sharply, pushing prices up further.

There is currently only one postal semen analysis provider operating at scale in the UK. Postal samples are not accredited, although most national providers quietly choose to overlook this detail. In practical terms, postal testing is generally good, while drop off laboratory testing is excellent, but the shrinking number of accredited labs means genuine choice is becoming rare.

PVSA has therefore become a major issue in the UK. Unfortunately, the system has managed to accumulate a remarkable number of regulatory bodies, advisory groups, and well intentioned quangos, none of which appear to make semen travel faster, cheaper, or more reliable.

Common problems encountered

Most PVSA problems are not scientific or technical. They are organisational.

Men submit samples too early. They forget to label the pot. They complete half the paperwork, or sometimes none of it. Time and date are omitted, which remains impressive given how often those details are requested. Some men do not collect the full sample but submit it anyway, presumably hoping for the best. Others ignore the abstinence instructions entirely.

None of this is malicious. It is simply human nature, and perhaps male nature in particular. Unfortunately, laboratories tend not to share this generous interpretation, and the result is usually the same. The sample is discarded, repeated, or both.

Cost and funding

TVVS pays for PVSA testing for NHS patients. The more tests that are required, the less economical the vasectomy becomes. After two to three tests, the profit for that patient has effectively disappeared, although this is a mixed and simplified calculation.

A perplexing case

One particularly instructive case involved a patient whose postal sample at 12 weeks showed 12,500 sperm per millilitre and would have met clearance criteria. However, at 20 weeks, a repeat test demonstrated live sperm.

Timing of testing and late failures

At TVVS, we test relatively late for two reasons. First, from a med economical perspective, later testing reduces the number of second samples. Second, I strongly suspect that many so called late failures are actually late detected early failures.

I have personally performed over 20,000 vasectomies and have never encountered a late failure. In contrast, the national ASPC audit, covering more than 125,000 patients, reports a late failure rate of approximately 1 in 2000. I believe earlier testing may contribute to this difference, although proving that definitively remains a challenge.

Conclusion

PVSA is far from a simple tick box exercise. In the UK, it sits at the crossroads of clinical safety, patient behaviour, healthcare funding, laboratory access, and an enthusiasm for regulation that occasionally outruns practicality. While national guidance provides an essential framework, progress will likely depend on a more pragmatic balance, one that keeps patients safe without tying the humble semen sample in quite so many administrative knots.