Hypospadias is a malformation in which the urethral meatus is located on the ventral side of the penis proximal to the tip of the glans, occurring from the balanopreputial sulcus to the perineal area. During the last decades, numerous observations on adverse trends and rising incidence of disorders affecting the male reproductive tract have been reported from the world, especially in the case of hypospadias having an incidence of 1 in every 250 male live births.¹² Concern has focused on whether exposure to endocrine-disrupting chemicals (EDC) with anti-androgenic activity is the cause of the increase. It has been observed that the foetus is especially sensitive to these endocrine disruptors (EDs) that can mimic or interfere with the natural hormones that control development. Common environmental factors that have an impact on intrauterine growth and morphogenesis of the genital tract are also considered to be the cause. In recent decades, it has been found that parental involvement in agriculture or parental exposure to pesticides (being anti-androgenic in nature) to be associated with higher risk of a wide range of congenital malformations;^3,4,5 however, the results from many studies are conflicting. Our previous case-control study⁶ that focused on the molecular basis of hypospadias highlighted that the presence of leucine allele (mutant allele) among individuals practicing farming was likely to increase their propensity of having a child with hyposapdias. If at all, EDCs with anti-androgenic like activity found among pesticides is a risk factor for the development of hypospadias, then it is a matter of serious concern especially in Indian context where 70% of the population's livelihood is based on farming and agricultural-based activities, exposing them to the toxic effects of various harmful agents.

The aim of the present study or the preliminary study was to first examine the incidence of hypospadias in Northern Indian region, to understand the communities at risk and to evaluate the various risk factors in the occurrence of hypospadias. As this is the first report on ‘Hypospadias’ in India, details from its incidence to risk factors are covered as a part of a preliminary research.

The study was carried out after obtaining the ethical clearance from the Department of Anthropology, University of Delhi and All India Institute of Medical Sciences (AIIMS), New Delhi. A total of 101 boys with hypospadias of 4–10 years old were prospectively entered in the study. All cases were diagnosed at the Department of Paediatric Surgery, All India Institute of Medical Sciences, India. Preoperative position of the urethral meatus was noted and phenotype was graded as mild, medium or severe. Subjects with un-descended testis, intersex disorders were excluded from the study. Only subjects with 46 XY phenotypes were included in the study. A total of 110 age, geography (North India), ethnicity (white) and language (Indo-European) matched controls from the general North Indian population without hypospadias or any history of genital abnormalities were collected via house-to-house surveys.

AIIMS is a multicentric hospital centred at New Delhi (a multicultural city), in which patient group from almost all castes, communities, regions subsist. Though the cases collected (from hospital) in the present study belonged to different communities making the samples heterogenous, maximum care was taken to match the controls with respect to communities observed among cases in order to get a clear scenario on the prevalence of hypospadias among Indian communities. All the communities included in the present study can be considered to fall under North Indian stock (Ancestral Northern Indian). Demographic and clinical data pertaining to reproductive profile of the mother, occupation of the parents and family history of genital abnormalities in male blood relatives were recorded for cases and controls.

Birth defects registered with the AIIMS Paediatric outpatient department (OPD) from the years 2003–2011 were scrutinized and the data on the number of hypospadias cases enrolled among them were calculated from AIIMS OPD registries and its frequency distribution was noted for the last 9 years.

Figure 1 depicted an increase trend in the incidence of hypospadias from the year 2003 (7.66%) to the year 2011 (9.33%).

Community-wise distribution of hypospadias cases showed a larger proportion of hypospadias cases (35.6%) among an agricultural-based community, Jats, followed by Muslims (21.78%) and Brahmins (11.88%) residing in Northern India. Analysis of the demographic data of cases on the basis of parental occupational status depicted a major group of children (72.27%) affected with hypospadias had their parents from rural background having agriculture as their primary occupation (Fig. 2).

Univariate analysis (Table 1) between cases and controls with respect to maternal age at first conception, age at menarche, birth weight of the affected child and folic acid supplementation during pregnancy was not found to be statistically significant (P>0.05). However, significant difference was observed between cases and controls with respect to vegetarianism (P<0.05).

A trend in declining male reproductive health with respect to hypospadias risk among Indian children was elucidated in the present study (Figure 1). These figures might be under-reported, especially in Indian context where the topic of ambiguous genitalia being a sensitive subject, has an enormous stigma attached. Due to this, the parents of the affected child may not report their child's abnormality and may further conceal it to prevent the traumatisations caused by the society. These derived results are, however, in agreement with other epidemiological studies and surveillance programmes held world-wide.⁷ Community-wise distribution of hypospadias cases depicted larger proportion of cases (35.6%) among an agricultural-based community (Jats) residing primarily in the Northern Indian belt. On comparing cases and controls with respect to demographic and clinical data, only vegetarianism was found to be associated with hypospadias (Table 1). These results are in agreement with a previous report⁸ which suggests that vegetarians have a greater exposure to phytoestrogens than omnivores thereby supporting the possibility that phytoestrogens have a deleterious effect on the developing male reproductive system.

On the basis of parental occupational status, a major group of children (72.27%) affected with hypospadias had their parents from rural background having agriculture as their primary occupation, i.e., individuals adhering to agricultural background are likely to be exposed to pesticides, which are EDs and anti-androgenic in nature. Though our study lacks the estimate of pesticide levels among cases, its role in hypospadias causation cannot be ruled out as foetal exposure to EDs with estrogen-like or anti-androgen-like activity found among pesticides could be a risk factor for hypospadias.

Jensen et al.⁹ hypothesised that the detrimental changes in male reproductive health that are becoming more apparent may be caused by the developing foetus having an altered exposure to EDCs with oestrogenic effects. According to Laden et al.¹⁰ even before the moment of conception, the embryo is exposed to its mother's background burden of persistent chemicals. Thus, an increase in hypospadias incidence (as earlier suggested by Baskin et al.¹¹ confirmed in the present study) could be attributed to two major hypotheses - one is a greater potential exposure of populations to the use of harmful pesticides. Second, due to recent advances in surgical techniques and assisted reproductive technologies, men with such defects after surgical correction are able to reproduce and are likely to transmit the genetic defects to their offsprings.⁶ The major issue in Indian context is that there is a dearth of studies related to these issues where large numbers of workers are engaged in agricultural and farming practices and are being exposed to various pesticides. This raises concern for health managers and policy makers as pesticides being used extensively in agricultural tracts are released into the environment and come into human contact directly or indirectly, thereby causing adverse effect on human health. As this study brings out the possible role of EDs in the aetiology of hypospadias, more replicative series involving large-scale population screening and monitoring of EDCs in the rural community are needed.

Abbreviations: CI, confidence interval; OR, odds ratio.

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