Expansion of Spinal Cord Injury Male Fertility Program: Needs Assessment Katarina Waters, DNP, FNP-C, APRN, University of Utah College of Nursing “In partial fulfillment of the requirements for the Doctor of Nursing Practice” February 1, 2013

Overview  Purpose  Problem (program limitation)  Objectives  Literature Review

 Implementation  Results  Future SCI fertility Program Plans

Project Purpose  To discover whether there is a need for SCI Male

Fertility Program at the University of Utah Health Care (UUHC)

SCI Outpatient Program Assessment  Location

Physical Medicine and Rehabilitation (PM&R) Outpatient Clinic at the University of Utah Health Care (UUHC)  Background information  Rehabilitation services for SCI population offered since 1965  Service areas include Intermountain states  Services  SCI specialized care, primary and urgent care to SCI population 

MISSION STATEMENT “To promote, support and realize maximum health and quality of life for individuals affected by spinal cord injury dysfunction” (UUHC, 2011).

SCI Outpatient Program

SCI Program Limitations  No ejaculatory dysfunction treatments or fertility

services offered for SCI men  Limited patient education on fertility and Nonsurgical sperm retrieval(NSSR) treatment methods options  Limited provider education how to use NSSR equipment

Project Significance  Over 260,000 individuals with SCI in USA  More than 12,000 new SCI cases are reported per

year in US  About 80% of SCI population are men  More than 50% SCI men are between ages 16-45  More than 90% male with SCI are infertile due to inability to ejaculate and have decreased sperm quality

Objectives  Objectives  To

develop and implement needs assessment plan for SCI Male Fertility Program  To summarize needs assessment findings  Provide recommendations

Literature review  Regaining sexual function was rated the highest

priority in paraplegics and second highest in tetraplegics (Anderson et al., 2004)-LOA 4.  Semen retrieval may be assisted by PVS in men with lesions above T10 (Beretta et al.,1989; Sonksen et al., 1994; Le Chapelain et al. 1998; Brackett et al., 2007)- LOE 4

 Up to 95% of cases with PVS results in ejaculation (Deforge, 2006: Deforge et al., 2004)- LOE 4

 Using a vibratory stimulation produces samples

with better sperm motility than from electrostimulation (Brackett et al., 1997; Ohl et al. 1997)- LOE- 2

Penile Vibratory Stimulators

Literature Review (cont.)  Semen retrieval may be assisted by EEJ in men who

failed PVS (Kolettis et al. 2002)-LOE 4  Surgical aspiration may be used to retrieve sperm if PVS and EEJ are not successful (Brindley et al. 1989)LOE 4.  Men with SCI have a good chance of becoming biological fathers with access to specialized care utilizing reproductive assisted technology (Kanto et al. 2008)

Electroejaculation Machine

Needs Assessment Evaluation Questions 1. What services are currently offered at the UUHC that are supportive of a new SCI Male Fertility Program? 2. What services are available locally and nationally to help with fertility in men with SCI? 3. What are the characteristics of outstanding SCI Fertility Programs nationally? 4. What components should be included in a comprehensive SCI Male Fertility Program? 5. What are the current trends of treatments for SCI male fertility? 6.What are current methods of ejaculation for SCI men? 7. How many SCI patients at the UUHC are interested in utilizing no-surgical sperm retrieval services for insemination?

NEEDS ASSESSMENT METHODS

Assess SCI Program regarding ejaculation problems, treatment and fertility options

Model SCI Fertility Programs Interviews

Key informant interviews

Modified Audit (type 2) Design Needs assessment for SCI Male Fertility Program at the UUHC

Needs assessment activities

(Adopted by Ovretveit, 1998,

Needs assessment patient survey Needs assessment provider survey Clinical practice guidelines review Evidence Based Practice literature review

Proposed program offerings

p.282)

Patient Needs Assessment Survey  27 questions formulated by E-survey design  IRB Approval of survey study on September 19,

 

  

2011 Survey given to 62 subject who met inclusion criteria Survey participation voluntary and anonymous Consent Cover latter reviewed Paper-pencil/on line form available All survey conducted at the PM&R outpatient clinic

Provider Needs Assessment Survey  22 questions by E-survey design  Survey sent by e-mails to 70 identified providers that

met inclusion criteria  Participation voluntary and anonymous/had a choice to be identified  By completing the survey consented to participate in the study  Protocol (inclusion criteria) 



Current or potential SCI provider Prescriptive practice in the state of Utah

Clinical Practice Guidelines Review  On line literature review  Review of “Sexuality and Reproductive Health

Clinical Guidelines for SCI” by Consortium of SCI Medicine (2010)

EBP Literature Review  Systemic review of male fertility by Spinal Cord

Injury Rehabilitation Evidence (SCRE), 2011

Key Informant Interviews  8 questions were formulated  6 interviews conducted and analyzed

PM&R  Dr. Jeffrey Rosenbluth  Shelly Pole, Clinic manager  Urology  Dr. William Brant  Colleen Lowe, NP  REI  Dr. Ahmad Hammoud  Andrology Lab  Dr. Douglas Carrell 

SCI Fertility Program Interviews  Model SCI Fertility programs were identified  The

Miami Project’s Male Fertility Research Program, Florida  Sharp SCI fertility Program, San Diego, CA

Patient Survey Results Age of Participants

Level of Spinal Cord Injury

35

cervical lumbar

30 25

20

thoracic unknown

10%

15 10

percent

17%

41%

5 0

32%

Patient Survey Results Type of Spinal Cord Injury incomplete SCI

60 Percent

complete SCI unknown

Methods of Ejaculation

9% 32%

50

40 30 20 10 0

59% Methods

Patient Survey Results  50% were single, 40% married 10% divorced or

separated  40%reported to have children that were born before injury, 5% after injury  50% of subjects experienced ejaculation  40% would like to have children in the future

Patient Survey Results EEJ Knowledge Self Rating

PVS Knowledge Self Rating excellent

excellent

very good Self rating

Self rating

very good good fair

poor 0

50 Percent

100

good fair poor 0

50 Percent

100

Patient Survey Results Importance of NSSR Services to Subjects

Likelihood of Obtaining NSSR Services

90

80

70 60

60

50

50

Percent

Percent

70

40 30

40 30 20

20 10

10

0

0 unimportant

important

Importance

unlikely

likely

Likelihood

Patient Survey Results Distance from UUHC

Issues Preventing to Obtain NSSR 40 35

30 101-150

Percent

Distance in miles

> 150

51-100

25 20 15 10

5

Jan-50

0 0

50 Percent

100

Issues

Provider Survey Results Field of Practice PM&R

Urology

OBGYN/REI

Neurology

3% 7%

17% 50%

23%

Andrology lab

Provider Survey Results  90% of providers treated SCI men  7 (26%) providers in Utah, from that only 1 provider

at the UUHC have tried PVS for semen retrieval  Total of 9 PVS procedures were done in Utah/year.  2 provider performed 2 PVS, 5 providers 1 PVS procedures per year.

Provider Survey Results Likelihood of Using PM&R clinic for Nonsurgical Sperm Retrieval services 100 80

percent

Current Referrals for SCI Related Fertility Issues  6 PM&R UUHC  Jeffrey Rosenbluth, MD  5 Andrology UUHC  Doug Carrel, MD  4 Urology UUHC  William Brent, MD and Jeremy Myers, MD  3 REI UUHC o Matthew Peterson, MD  2 Urology in Provo Stewart Landau, MD  1 Urology at Alta View Hospital  Richard Labaski, MD

60 40 20

0 unlikely likely likelihood

Provider Survey Results  No providers had done EEJ at the UUHC  Only 1 provider has performed EEJ procedures in

Utah (outside UUHC)  All EEJ samples were used for sample analysis, insemination and cryopreservation

Key Informant Interview Summary  All 6 key informants were not aware of NSSR and

fertility services offered specifically to SCI male population at the UUHC  None of key informants have being using any patient education materials related to the NSSR  Most informants except SCI specialist have limited knowledge of SCI male fertility needs  All informants agreed that there is a need for SCI Male Fertility Program at the UUHC and will need interdisciplinary team

Model SCI Program Staff Interviews Summary  For successful SCI Fertility Program  Show

an interest to the SCI male population  Educated and trained providers for PVS and EEJ procedure  Financial and staff support  Proper selection of SCI patients for PVS and EEJ procedures followed by algorithm  Interdisciplinary team approach  Prevent complications of NSSR procedures

Clinical Practice Guidelines Summary  Most men with SCI will experience some erectile and ejaculatory    

dysfunction Assistance with fertility for biological fatherhood is often necessary For men with incomplete lesion natural ejaculation may be possible For couples considering pregnancy may needs to review several factors that can affect fertility outcomes Options for NSSR  Manual stimulation  Use of sympathomimetic drugs  PVS  EEJ

Conclusion  In favor of SCI Male Fertility Program at the UUHC  100% of key provider informants  close to 79% of SCI providers  60 % SCI subjects reported likelihood of obtaining NSSR (PVS or EEJ) services for fertility reasons  SCI providers and patients surveys participation  Patient survey available for 15 clinic days (62 patients)  Provider survey available for 20 business days (30 providers)

SCI Male Fertility Program Plans  PM&R division approval  2 FERICARE  Consent form  Grant money to purchase EEJ machine

 Visit “SHARP Rehab SCI Fertility Program”, San

Diego, California  Visit “The Miami Project to Cure Paralysis, SCI Fertility Program”, Florida

SCI Male Fertility Program Plans (cont)  Selection of appropriate patient education related to

NSSR  Initial SCI fertility assessments, consultations and NSSR services will be performed at the PM&R outpatient clinic with other fertility services consultation

SCI Male Fertility Program Plans (cont)  Interdisciplinary Team at the UUHC  SCI Providers and Staff  Andrology Staff  REI Specialist  OB/GYN Specialist  Physical Therapist  Occupational Therapist  Psychologist  Urologist

SCI Male Fertility Program Plans (cont)  Develop new program business plan with policies

and procedures related to NSSR procedures  Seek financial support from   

UUHC financial office grants local/national donors

Acknowledgements and Thanks  Chair 

Thomas Mansen, RN, PhD

 Content experts  

Jeffrey Rosenbluth, MD Dana Hughes, RN, PhD

 Other field experts    

Jackie Smith, PhD Nancy Brackett, PhD Stephen Seager, DVM Elie Elovic, MD

 Husband Doug  Children Marko and

Bella  Friends  Classmates

Questions? SCI Male Parenthood is possible!

References             

References Alexandrino, A.P., Rodrigues, M.A.F., Matsuo, T. (2004). Evaluation of serum and seminal levels of prostate specific antigen in men with spinal cord injury. Journal of Urology. 171:2230–2. Alexandrino, A.P., Rodrigues, M.A., Matsuo, T., et al. (2009). Evaluation of seminal citrate level by 1H nuclear magnetic resonance spectroscopy in men with spinal cord injury. The Journal of Spinal Cord Medicine, 47 (12), 878–881. Alexandrino, A.P., Rodrigues, M.A., Matsuo, T., et al. (2011). Evaluation of seminal zinc levels by atomic absorption in men with spinal cord injury. Spinal Cord, 49(3), 435–438. Alter, C., & Murty, S. (1997). Logic modeling: A tool for teaching practice evaluation. Journal of Social Work Education, 33 (1). Anderson, A. (2000). Using theory of change in program planning and evaluation. Aspen Institute. PowerPoint presentation at the annual meeting of the American Evaluation Association, Honolulu, HI. Anderson, K.D. (2004). targeting recovery: priorities of the spinal cord-injured population. Journal of Neurotrauma, 21(10), 1371-83. Arafa, M.M., Zohdy, W.A., Shamloul, R. (2007). Prostatic massage: a simple method of semen retrieval in men with spinal cord injury. International Journal of Andrology, 30,170–173. Basu, S., Lynne, C.M., Ruiz, P., et al. (2002). Cytofluorographic identification of activated T-cell subpopulations in the semen of men with spinal cord injuries. Journal of Andrology, 23, 551–6. Bird, V.G., Brackett, N.L., Lynne, C.M., et al. (2001).Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury. Spinal Cord, 39, 514–519. Blanchard-Dauphin, A., Rigot, J.M., Thevenon, A. (2005). Treatment of ejaculation disorders by Midodrine (Gutron) per OS. Retrospective study of about 16 subjects. Annual Re-adaptive Medical Physiology, 48, 34–40. Boomsma, C.M., Heineman, M.J., Cohlen, B.J., et al. (2007) Semen preparation techniques for intrauterine insemination. Cochrane Database Systemic Review. (4):CD004507 Brackett, N.L., Padron, O.F., Lynne, C.M. (1997). Semen quality of spinal cord injured men is better when obtained by vibratory stimulation versus electro-ejaculation. Journal of Urology, 157, 151–157. Brackett, N.L., Ferrell, S.M., Aballa, T.C., et al. (1998). Semen quality in spinal cord injured men: does it progressively decline post injury? Archives of Physical Medicine and Rehabilitation, 79, 625–628.

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