Abstract Introduction Over 500,000 men undergo vasectomy in the U.S. annually. Although found to be 99.7% successful, the cost of vasectomy failure that results in an unplanned pregnancy far outweighs the cost of follow up semen analysis to ensure success. Despite the cost-benefits of post-vasectomy semen analysis (PVSA), compliance ranges only 30%-87%. Challenges include access to care, cost, and inconvenience of time4. Mail-in PVSA may help address these challenges and improve compliance, particularly in socially vulnerable and rural communities. Objective To examine geographic and socioeconomic community-level factors linked to mail-in PVSA completion in Texas. Methods We prospectively analyzed data from Texas men after undergoing vasectomy who received a Fellow mail-in PVSA kit between 2021–2024. Home ZIP codes were linked to the Distressed Community Index (DCI), a measure of economic well-being across US communities. The primary outcome-mail in PVSA completion within 40 weeks of being provided a test kit-was evaluated against region, DCI, and kit ordering setting. Chi-square tests and multivariable logistic regression were used, and statistical significance was assessed at the 0.05 level. Results Of 4,744 men included, 81.1% (3,849) completed mail-in PVSA testing. Compliance rates were lower among individuals living in urban areas, in the North Texas region, those residing in communities “at-risk” of socio-economic distress, and those who received their kit in a clinic (Table 1). On multivariate analysis, residence in a rural area was associated with higher completion rates (OR 1.50, 95% CI 1.12–2.04), and men who ordered their kits direct-to-consumer where significantly more likely to be compliant than those receiving their kits in a clinic (OR 10.33, 95% CI 5.01–26.26). Conclusions Men in rural areas of Texas were 74% more likely to complete mail-in PVSA, even after adjusting for social determinants of health. Direct-to-consumer users were also more likely to complete testing than clinic-ordered users. Mail-in PVSA shows higher adherence than historical clinic-affiliated methods (30–50%). Further research is needed to explore regional factors influencing completion, such as cultural attitudes, access to postal services, health literacy around male infertility, and insurance policy. In summary, mail-in PVSA testing may dramatically improve compliance for men in rural areas, and potentially decrease the risk of unplanned pregnancies. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow