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Barriers to Use of Semen Analysis in the Adolescent Varicocele: Survey of Patient, Parental, and Practitioner Attitudes
Ronnie Fine, MD, Jordan Gitlin, MD, Edward F. Reda, MD, Lane S. Palmer, MD.
Cohen Children's Medical Center of New York, Lake Success, NY, USA.

BACKGROUND – A semen analysis (SA) is an integral part of the evaluation of the adult varicocele; however, few studies have assessed the role of a SA in the work-up of the adolescent presenting with a varicocele. Our goal was to identify barriers to the routine incorporation of SA in the assessment of these patients by surveying patients, their parents, and pediatric urologists.
METHODS Two surveys were used. (1) An anonymous electronic survey was emailed to the members of the Society for Pediatric Urology. The survey consisted of 14 multiple-choice questions and 2 open ended questions regarding the prevalence of SA utilization in practice, barriers to use of SA, indications for varicocelectomy, and demographics. (2) An anonymous survey was given to patients and parents (presenting for initial evaluation of a varicocele to evaluate their baseline level of knowledge about a semen analysis, their attitude towards producing a SA and discussing it; this was assessed prior to consultation.
RESULTS The practitioner survey response rate was 29% (n=167). The majority of responders were male (86%), over 15 years in practice (51%), and seeing 1-4 adolescents with varicoceles per month (56%). More than half (53%) never ask for SA, whereas only 12% routinely asked for SA in patients that they considered eligible. While 92% recommended surgery based on physical exam findings, only 38% based the recommendation on SA results. Among those who utilize SA, the eligibility criteria were primarily Tanner 5 (17%) or over age 18 years (45%), and only 22% of practitioners trended SA over time. 48% of all responders had some degree of discomfort asking for a SA, citing ethical concerns of labeling an adolescent as sub-fertile, religious reasons, and discomfort due to the presence of the parents in discussion. 90% of practitioners who cited discomfort never order a SA for these patients. Men and women practitioners were equally likely to feel uncomfortable requesting a SA (48% vs 44% respectively). Physicians >15 years in practice were the group most comfortable requesting a SA (60%). The average age of the 33 patients surveyed was 15.4 years. The most common reason cited for discomfort with SA collection is not knowing what it is (9/33 patients; 5/33 parents). Patients also cited that they were embarrassed (7); uncomfortable discussing sex related issues with parents (5). No one cited not wanting to know the results as a reason for avoiding the test
CONCLUSIONS There are several barriers to using SA in managing adolescents with varicoceles. Pediatric urologists in the United States under-utilize SA as part of the work up, management, and surgical decision-making. In this pilot survey of patients and parents we noted that they are often reluctant to provide a SA due to lack of knowledge about the process. We believe that recognizing, and then breaking through these barriers, would improve our care of these patients as we will be able to directly assess the impact of the varicocele on seminal quality and thus be better informed to determine which patients require surgical intervention.

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