ICMR BULLETIN VOL. 24-No.-9-SEPTEMBER-1994.pdf
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LONG TERM HEALTH CONSEQUENCES OF VASECTOMY
Surgical sterilisation is the most effective, safe and
and malignancies, several investigators initiated studies
economical long-term contraceptive method for both
on the long-term health consequences of vasectomy. In
men and women. With increasing global awareness
the early eighties data pertaining to follow up for
about these advantages, sterilisation has become the
periods upto a decade were obtained and reported. In
most widely used method of contraception. The number
the late eighties, data on substantially large numbers
of couples using sterilisation is now estimated to be
of men followed up for periods upto 20 years oHonger
170 million; the figure is expected to reach 270 million
became available from some of the developed and
by the year 2000. Ample data exist to show that
developing countries. Results from these studies indi
vasectomy is simpler and safer than tubectomy; in spite
cated that overall morbidity and mortality rates in men
of this the estimated number of couples using vasectomy
who had undergone vasectomy were essentially similar
the world over is only 42 million. In the last two decades
to or even lower than that of controls drawn from the
specific efforts have been made to inform the population
same community. However, two studies in USA showed
of the safety of vasectomy and reassure them that
that the risk of cancer of the prostate, the second most
vasectomy does not affect sexual performance, This has
common malignancy
resulted in an increase in the acceptance of vasectomy
men who iiad undergone vasectomy. A study from South
developed and developing countries.
Korea reported an increase in the risk of myocardial
in some of the
in men in USA, was higher in
infarction in vasectomised men. Publication of and
In the sixties it was generally assumed that the
surgical excision of a small portion of the vas would
not have any systemic effects. Immunological studies
in
men
who
had
undergone
vasectomy
showed
that over 50 per cent developed antisperm antibodies
which persisted for ten years or longer. There have been
conflicting
reports
of
profile in vasectomised
the
long-term risks and benefits of vasectomy have raised
the question of the applicability of these findings in
the Indian context.
In the nineties India will witness the impact of the
in
hormonal
ongoing demographic transition,
Concerned
over the
stantial increase in the proportion and number of persons
changes
men.
public debate on the conflicting global data regarding
in terms of the sub
potential long-term consequences of these changes on
above 50 years of age. The prevalence of cardiovascular
prevalence of cardiovascular and autoimmune diseases
diseases (CVD), cerebrovascular accidents (CV^) and
Division of Publication & Information, IC MR, New Delhi - 1 10 02^
malignancies including cancer prostate is higher in men
Table I. Prevalence of vasectomy
beyond 50 years of age; hence physicians will be seeing
more patients with these illnesses even if the prevalence
Regions/Countries
of all these diseases remain unaltered. Added to this
is the fact that most of the estimated 13 million Indian
men who had undergone vasectomy did so prior to 1977
No. of
couples
using
vasectomy
(%)
No. of
couples
relying on
vasectomy
(millions)
6.0
23.0
No. of
couples
using
tubectomy
(%)
and will be 50 years or older in the nineties and some
may develop CVD, CVA or cancers. It is therefore
Asia
essential that epidemiological studies are carried out
China / ' r ..
.8.0
18.1
28.0
in India
India
7.0
13.0
22.0
Thailand
6.0
2.3
S.Korea
11.0
to assess the long-term risks and benefits
associated with vasectomy and draw balanced conclu
sions regarding the safety of vasectomy in the Indian
context, so that informed choices among the available
contraceptive options could be made . Global data on
health consequences
of
vasectomy,
their relevance
to the Indian situation and the ongoing ICMR studies
to obtain data on the long-term risks and benefits
associated with vasectomy in India are reviewed here.
Prevalence of Vasectomy
Near East, North Africa
0.5
<0.5
Sub-Saharan Africa
0.5
0.5
Latin America
0.7
0.4
Australia and New Zealand 13.0
0.4
Australia
10.0
28.0
New Zealand
23.0
19.0
Europe
3.0
UK
12.0
provides permanent protection against conception. Ample
Netherlands
11.0
global data clearly demonstrate that vasectomy has no
North America
13.0
5.2
All developing
countries
5.0
32.3
All developed
countries
5.0
9.2
Global
5.0
41.5
For couples who have completed their family, vasec
tomy is a simple,
effective,
safe procedure which
short-term adverse effect on health or sexual perform
ance of men. Improved awareness about these advan
tages has led to increased acceptance of vasectomy in
both developed and developing countries. The most
spectacular increase had occurred in New Zealand and
UK . Between 1976 and 1986,
vasectomy rate in
creased from 9 to 23 per cent
in New Zealand and
from 2 to 11 per cent in
Sri Lanka,
UK. China,
17.5
South Korea,
Source: Ref. 1
Nepal and Thailand among developing
countries have also shown a progressive increase in
prevalence of vasectomy during the eighties. It is estimated
Changing Trends in Vasectomy in India
that (as of 1992) nearly 42 million couples depend on
From
to
inception
date,
the
major
focus
of
vasectomy fbr contraception (Table I)1 and the number
India's National Family Wefare Programme has been
is growing.
on sterilisation,
both
fifties and sixties,
China and India have the largest number of vasectomised men in the world. In India,
in spite of the
to
in
provide hospital- based
services.
Health
men
efforts
and
were
women.
In the
directed
mainly
vasectomy and tubectomy
education
through
mass
media
fact that both vasectomy and tubectomy were introduced
or inter personal channels was minimal. Literacy rates
Family Welfare Programme from its
were low and the outreach of mass media was limited.
in the National
inception and vasectomy was well accepted in the fifties
and sixties,
only 7 per cent of the eligible couples
In spite of these,
acceptance of vasectomy was quite
high. With improved outreach
through
the camp
are currently protected by vasectomy. Contrary to the
approach, vasectomy formed 74 per cent of all
global trend there had been a progressive decline in
lisations in 1970. However, during the last two decades,
vasectomy acceptance in India during the last 20 years.
there has been a sharp and progressive decline in the
90
steri
contribution of vasectomies to the total number of
rare. Reported incidence of complications range from
sterilisations in India (Table II)2. The reasons fbr this
0.1 to 3.0 per cent1. Haematoma and infections are the
decline have not been clearly documented.
two immediate complications; neither is life threatening
and both respond readily to treatment. With training
Table II. Changing trends in vasectomy in India
Vasectomy
(as % of total
si:erilisation)
Year
No.of
vasec
tomy
No.of
tubec
tomy
1960
37,596
26,742
64,338
58.4
10,55,860
3,66,258
14,22,118
74.2
1969-70
Total
and adequate attention to asepsis, these complications
can be minimised. Thus, the procedure is ideally suited
fbr use in the primary health care set up.
Vasectomised men have to be specifically reassured
that the surgery will not in any way impair their sexual
performance. There is a lag period of 3-6 months before
all the sperms disappear and the contraceptive effect
1979-80
4,72,687
13,05,237
17,77,924
26.6
1989-90
3,41,581
38,46,582
41,88,163
8.2
men
1990-91
2,54,982
38,67,648
41,22,630
6.2
prevent inadvertent pregnancies.
1991-92
1,74,008
39,15,170
40,89,178
4.2
of vasectomy can be relied upon; hence vasectomised
have to be clearly instructed
to
use additional
reliable contraception fbr the subsequent six months to
Biochemical Changes Following Vasectomy
Source: Ref. 2
Figures for 1991-92: Provisional unpublished data from
Ministry of Health & Family Welfare.
Effect of vasectomy on the function of the pituitary-
gonadal axis,
epididymis and prostate had been ex
tensively investigated in the seventies both in India and
The All India Post Partum Programme began in
1971 and with it the availability of tubectomy,
part of
abroad. Most of these studies4-6 indicate that there is
as a
no alteration in the pituitary-gonadal axis, testicular
Maternal and Child Health (MCH) services,
function or androgen levels in vasectomised men. Semen
from primary health centres (PHCs) to tertiary care
analysis in these
hospitals, improved. Vasectomy services, however, did
reduction in the secretory function of the prostate;
not get integrated into routine surgical practice. Unlike
however,
tubectomy services, vasectomy services did not reach
exact reasons fbr these changes are not known. No
men indicated that there was some
the reduction was not progressive7,8. The
out fbr potential clients, address their anxieties, prob
adverse health consequences attributable to these changes
lems or conveniences. The fact that the health infra
have as
yet been reported.
structure has the potential fbr carrying out vasectomy
and acceptance of the method among men does exist
in India was proved in 1976 when over six million
vasectomies could be done. Obviously the potential for
vasectomy to play the key role in the
Welfare Programme has
National Family
not yet been fully exploited.
Currently the Government of India is taking
steps to
popularise vasectomy and persuade men to participate
in the Planned Parenthood movement through improved
acceptance of this simple procedure.
Short -Term Sequelae of Vasectomy
Vasectomy is an easier, simpler and safer procedure
Immune Changes Following Vasectomy
Antibodies to spermatozoa have been detected in
over 50 per cent of men 3 to 6 months after vasectomy.
These antibodies persist for a long time9. There have
been speculations as to whether these antibodies may
form circulating immune complexes which may result
in adverse health consequences. It has been postulated
that the immune complex may (i) get deposited in the
arterial wall leading to intimal injury and accelerated
atheroscl.iosis; (ii) lead to or hasten the progress of
a variety of autoimmune diseases such as rheumatoid
than tubectomy”. Every practicing physician with minimal
arthritis; (iii) heighten allergic disorders; and (iv) alter
additional training can develop the skills required for
the risk or progression of some malignancies. Data from
performing vasectomy safely and providing follow up
epidemiological studies have not substantiated any of
care. Immediate complications following vasectomy are
these hypothesis.
91
Epidemiological Studies on Long-Term Health
Consequences Associated with Vasectomy
Following the publication of conflicting results
regarding hormonal changes and consistent finding of
immune changes in vasectomised men, concerns were
expressed about the potential health consequences of
these changes. Therefore during the eighties several
attempts were made to obtain information on the long
term health consequences of vasectomy through
epidemiological studies.
Two approaches have been extensively used by
communities or among persons attending hospitals;
controls
were individuals who did
not suffer from
these disease and were drawn from the same community
or the hospitals
after
matching
fbr
age,
race and
socio-economic factors. Information on the presence
or absence of the factor under investigation (vasectomy)
in the cases and controls is collected. The relationship
between the disease and the factor under investigation
is computed by comparing the frequency of the factor
in the cases and the control group. This type of case
control study had been extensively used to investigate
the possible association between specific diseases and
epidemiologists to obtain data on the long-term health
vasectomy both in developed and developing countries,
status of vasectomised men. In one, the starting point
because it is relatively easy to collect information on
is the factor under investigation (vasectomy). Efforts
the vasectomy rates in relatively large numbers of
were made to identify well defined population groups
persons suffering from the specific diseases and the
where accurate records of vasectomy status and major
controls who are free from these diseases, within the
morbidity and mortality data were available for all the
existing constraints of availability of accurate hospital
members for the lAst decade or more. From the existing
records, time and money.
records, persons who had undergone vasectomy were
identified; one or more persons matched fbr age, race
and socioeconomic status, were selected from the same
population group. Through record linkage, information
on the morbidity and mortality in these two groups of
individuals was extracted from existing records and
"relative risk of morbidity computed. For obvious rea
sons matching fbr behavioural and life style variables
was not possible, even though it is known that life style
variables influence both the acceptance of vasectomy
and morbidity profile. Yet another problem in all these
studies was the fact that even when morbidity/mortality
data were extracted from the records of over 10, 000
persons, the number of persons suffering from any
specific morbidity was very small; consequently com
puted RR tends to have very wide confidence intervals
(Cis). Because of the ready availability of computerised
records of events related to health of the individuals
this type of epidemiological investigation (variously
termed as retrospect!ve/historical cohort studies or as
record linkage studies) is used to explore association,
if any, between vasectomy and CVD, C" and cancers
in developed countries. Because of the absence of these
The major problem in interpreting the results from
the studies of either type
is the accuracy
with which
controls have been "matched" and the elimination of
any bias in the selection of the controls. It is well known
that life style differences
acceptance
influence both vasectomy
and prevalence of CVD, CV^ and some
malignancies, but it is not possible to match the life
styles. As the etiological factors fbr many of the
malignancies and autoimmune diseases are still poorly
understood, matching except fbr obvious socio-demo
is not possible. Even when all care
graphic factors,
is taken to match fbr the known factors, the possibility
that some as yet unidentified factor might account fbr
the observed association cannot be ruled out.
of all these problems,
Because
interpretation of the reported
associations between specific diseases and vasectomy
from epidemiological studies using either the Mretro
spective cohort" or the "case controlw approach
is
difficult and at times an unproductive exercise; detected
associations
can
at best be taken as indication of a
possible relationship, not necessarily causal, which
needs to be confirmed..
types of records, such studies are not possible in
developing countries.
Cardiovascular Diseases
In the second approach, individuals suffering from
Baboons fed on lipid rich diet when repeatedly
specific diseases under investigation is the starting
immunised with foreign proteins have been shown to
point. Patients with the disease (eg. acute myocar
develop more severe atherosclerosis than the pair
dial infarction) were identified either in well defined
fed controls10.
92
In
1978,
Alexander
and Clarkson11
reported that diet induced atherosclerosis developed
CVD and vasectomy18, and not all studies
more extensively in the abdominal aorta, carotid arteries,
similar reduction in the CVD, suggests that
distal segments of coronary artery and the intracranial
sociation is not causal, but might have been mediated
cerebral arteries in vasectomised cynomolgus monkeys
by the self selection bias of the men who had undergone
vasectomy. Healthier men may choose to undergo vasec
same diet. They postulated that the rapid progression
tomy and hence the lower morbidity and mortality rate.
immune complexes to sperms in the vessel wall and
consequent endothelial damage and increased perme
ability11. A decade later the same investigators reported
that long- term follow up studies in these monkeys did
not reveal any association between development of CVD
and vasectomy12.
Among
the developing countries, South Korea
where vasectomy acceptance had risen steeply in the
last
decade and China where the largest number of
vasectomised men live have undertaken large scale
studies to assess the CVD risk. A community based
study on farmers from rural communes in Sichuan
province
from China showed that age specific death
In 1981, the WHO reviewed the available data and
rates fbr all causes including CVD were lower in
concluded that there was no clinical or epidemiological
evidence
to indicate that there is any increase in
vasectomised men (RR 0.39; 95% CI 0.3-0.5). The
cardiovascular, endocrine or autoimmune diseases in
some difficulties in the identification of the exact cause
vasectomised men13. However, concern about these
of death in this study. Simultaneously a community
potential risks following vasectomy persisted and several
based study was undertaken to assess 'risk factors* for
investigators attempted to obtain data on long-term
CVD in
health consequences associated with vasectomy. The
the same community who had not undergone vasectomy.
investigators had, however, reported that there were
4596 vasectomised men and 4340 men from
in
Vasectomised men were 'healthier' when compared to
the seventies cardiovascular and cerebrovascular dis
controls as assessed by prevalence of hypertension (RR
major causes of death in men in
0.8; 95 % CI 0.7-1.0), ischaemic heart disease (RR 0 5;
developed countries. Studies conducted in the UK and
95%CI 0.3-0.7), biochemical parameters, resting ECG
fbcus of the initial studies was on
eases were the
CVD, because
USA in the eighties in men who had undergone va
(RR 0.7; 95% CI 0.5-0.9)and stress test ECG ( RR
sectomy two to ten years earlier, showed that the risk
0.9; 95% CI 0.6-1.2)21.
of CVD was either unaltered or lower in vasectomised
men14*17.
.
9
the as
than in sham vasectomised control monkeys fed on the
of the lesion could be due to deposition of circulating
•
showed a
The South Korean study which was based on the
analysis of death certificate in four major cities did not
By the late eighties and early nineties, in many of
find any difference in risk of death due to cardiovascular
the developed and developing countries , there were
or cerebrovascular disease between vasectomised men
sufficient numbers of men who had undergone vasectomy 15-20 years earlier and were in their fifties and
sixties, making it possible to undertake large scale
studies to obtain information on long-term cardiovas
cular disease risk in men who had undergone vasec-
tomy18-23. Data from USA involving 14,540 men who
had undergone vasectomy prior to 1978 and 12,392
controls showed that the overall mortality rates in
vasectomised men were lower and this was mainly due
to lower CVD mortality rates in vasectomised men18.
There were no differences in the risk of fatal or non-
and controls (adjusted odds ratio 1.0; 95% CI 0.4-
2.4产.However, the same investigators reported an
increased risk of acute myocardial infarction (adjusted
odds ratio 2.6; 95% CI 1.1 - 6.1), 10-14 years after
vasectomy in a hospital based case control study. In
this study 163 men with acute myocardial infarction
were compared with controls who were admitted to the
same hospital fbr
other ailments including cancers23.
The excess risk disappeared (adjusted odds ratio 1.1)
when only the controls with digestive tract disorders
were considered.
fatal myocardial infarction rates between the vasectomised
To sum up, available evidences suggest that the risk
men and controls. Both coronary artery disease and
of CVD and cerebrovascular diseases in vasectomised
myocardial infarction (fatal and non-fatal) were lower
men is either unaltered or is lower. The conflicting time
in men who had undergone vasectomy 20 years earlier18.
trends found in the same study18 and differences between
But the fact that
even in the same studies there were
studies in the same country22,23 suggest that the reported
no consistent time trends in the association between
lower risk of CVD in vasectomised men might be due
93
to the differences in the life styles of the vasectomy
those who have not, and hence may have different
is not a consequence of the procedure
malignancy risk should also be kept in mind while
acceptors and
interpreting the results of studies investigating the risk
per se.
In India, the ICMR had carried out a case control
study on several biochemical parameters including lipid
profile in vasectomised men among industrial workers
in Maharashtra in the early eighties. There were no
significant differences in any of the biochemical parameters
between cases and controls24. So far, epidemiological
studies exploring association, if any, between vasec
tomy and cardiovascular or cerebrovascular diseases
largest number of vasecto
mised men in the world. Majority of them had under
gone vasectomy
more than 15 years earlier and are
likely to experience in the nineties, some of the long
term risks/benefits associated with vasectomy. Data
from some studies carried out in India indicate that there
is an increasing prevalence of CVD in the country23.
Reported prevalence of hypertension is between 2.315.4 per cent depending upon the type of population
studied; prevalence of ischaemic heart disease ranged
from 1.7-6.5 per cent. It is estimated that in India there
are 22.5 million persons suffering from hypertension
and 12 million from ischaemic heart disease25. Of these,
approximately two thirds are men. Studies in non
resident Indians settled abroad have shown that CVD
rates in Indians in these countries are higher than those
of Caucasian
Most of the available data on morbidity and mor
tality due to cancer in vasectomised men come from
record linkage studies
in UK and USA. A large
retrospective cohort record linkage study in USA,
involving over 10,000 vasectomised men and a similar
number of controls revealed that though both groups
had similar incidence rates fbr 98 diseases including
have not been carried out in India.
India has the second
of malignancies in vasectomised men.
citizens26. In view of the large number
of vasectomised men in India and relatively high preva
lence of CVD in Indians, even a relatively small re
duction in CVD risk (RR 0.8-0.9) in vasectomised men
will benefit relatively large number of individuals.
ICMR has initiated a hospital-based case control study
to obtain data regarding CVD risk in vasectomised men
in India.
various cancers, the death rate from cancers in vasectomised
men was half that seen in the control group17. Almost
all medium and long-term follow up studies have shown
that the risk of morbidity and mortality due to cancers
in vasectomised men were either similar to or lower
than that in the control groups.13*20. However, isolated
findings of an increased risk of lymphomas, lung cancer
and cancer prostate in vasectomised men have been
reported from some studies18-27. These conflicting re
ports on association between vasectomy and specific
malignancies could be because of the fact that
even
when morbidity data over one or two decades in over
10,000 men who had undergone vasectomy and matched
controls are extracted and analysed, the number of
persons suffering from any given specific disease is so
small that it is not possible to rule out that the asso
ciation
might be due to chance. Yet another reason
for the variations in lhe reported
trend
might he
problems in selecting appropriate "controls”. Thus
while overall data suggest that there is no association
between cancers and vasectomy,
further studies are
needed to explore association, if any, between specific
types of malignancies and vasectomy.
In India the prevalence of malignancies is very low
as compared to developed countries28-29. Cancer cervix
Malignancies and Vasectomy
and cancers of the oral cavity account for nearly half
Two major hypotheses have been proposed linking
of all the malignancies. Prevalence of cancer prostate.
vasectomy with altered prevalence of malignancies.
lymphomas and hormone dependent tumours is low. It
These are (i) that the presence of antisperm antibodies
is therefore, essential to find out whether the findings
may alter the immune response and hence alter the risk
from the developed countries regarding the association
or progression of malignancies; and (ii) the
altered
between malignancies and vasectomy are applicable to
sex hormone profile in vasectomised men may modify
the Indian population. The ongoing ICMR case control
the prevalence or progression of hormone dependent
study on cancers other than genito-urinary tract malig
tumours. The possibility that men who had undergone
nancies and vasectomy, is expected to provide some
vasectomy may differ in their life styles and habits from
leads in this aspect during the next two years.
94
detected during autopsy in 50 per cent or more men
Specific Malignancies
over the age of 60 years and in this group the incidence
is similar in all countries32. However, there are marked
Cancer testis
differences in prevalence of clinically obvious cases of
Cancer testis is a relatively rare malignancy, inci
dence being
highest
in
men
in
their
thirties.
It
has been postulated that vasectomy might protect against
testicular tumours through enhanced immunological
surveillance19, but there is no evidence to support this
or to suggest that vasectomy may lead to increase in
the incidence or hasten the progression of testicular
cancer.
cancer prostate between developed and developing coun
tries. Part of the observed differences could be due to
inclusion of a large number of subclinical cases of
cancer prostate detected in biopsy tissues obtained from
patients with benign prostatic hyperplasia and the screen
ing by prostate specific antigen and other tests for early
diagnosis of prostate cancer, in the developed countries.
However,
Strader et alM reported an association between
there appear to be real differences both in
the prevalence and progression of the tumour not only
vasectomy and testicular cancer in a case control study
between countries but also between different races in
undertaken through telephone interviews. The associa
the same country33*34.
tion was seen only in Catholics and was most probably
Over the last decade there has been a substantial
due to under-reporting of vasectomy by Catholics in
increase in the prevalence of cancer prostate in some
the control groups. Cale et aP' who undertook a retro
spective study of all patients who had been diagnosed
as having testicular cancers in West Lothian district in
the UK reported that the age standardised incidence of
testicular tumours was 4.2 times higher in vasectomised
patients. All the tumours were detected between 3
months to 4 years (mean 1.9 years) after vasectomy
suggesting that some of these might have been present
at the time of vasectomy. Subsequently two large record
linkage studies, one from the UK19 and the other from
the USA”，failed to detect any increase in the risk of
testicular tumours in vasectomised men.
of the developed countries like the USA and UK.
Currently cancer prostate is the second most common
cancer in USA and some European countries. Globally
it ranks as the fifth most common cancer in men32.
However, reported prevalence in several developing
countries including India and China is low. Incidence
of cancer prostate in USA is 91.2/100,000; in India
incidence ranges between 1.9 to V.l/lOOjOOO28,29,33. It
is estimated that there are only about 100,000 patients
with cancer prostate in India. Among the developed
countries there are substantial differences in the inci
dence and mortality due to
cancer prostate
between
There are no sound biological reasons to suspect
USA and New Zealand and between the Whites and
a causal relationship between vasectomy and testicular
Blacks in USA28-34. The reasons for the observed large
tumours. The conflicting reports might in part be
differences are not known.
attributed to one or more of the following confounding
Reports exploring the association between vasecto
factors:(i) vasectomised men are a self selected group
my and cancer prostate date back to the mid eighties.Prior
with as yet not clearly known factors associated with
to 1990,
low prevalence of testicular cancer; (ii) men with small
linkage study37 had reported that there was no asso
two case control studies35,36 and one record
testicular tumours who wanted to undergo vasectomy
ciation between cancer prostate and vasectomy; while
might have been 'rejected', so that those who underwent
another case control study reported that vasectomised
vasectomy were a screened selected group with no
men were at a higher risk38.
testicular tumours; and (iii) testicular cancers are more
often seen in Caucasians with higher education and
4 In 1990 two hospital-based case control studies
income, a group which in UK and USA was more likely
reported an increased risk of cancer prostate in vasec-
to seek vasectomy.
tomised men39-40. Rosenberg et aP9 reported an age
adjusted RR of 5.3 (95% CI 2.7-10.0) in a study
comparing 220 patients of cancer prostate and 571 men
Cancer prostate
without any cancer; when the same patients were
Very little is known about the etiology of cancer
prostate. It is known that 'silent' prostate cancers are
、A
)切
library
DOCUMENTATION
compared with 960 controls with cancers other than
cancer prostate the
RR was 3.5 (95% CI 2.1-6.0).
95
Mettlin and coworkers40 reported that the RR was 2.2
decade some attempts were also made to obtain these
(95 % CI 1.0-4.6) in another hospital-based case control
data in developing countries through hospital and
study of 614 cancer prostate cases and 2588 controls
community-based case control studies21,23. All the available
with cancers other than cancer prostate.
data indicate that the overall morbidity rates in vasectomised
Subsequently four record linkage studies explored
the association. Two of these studies conducted on
health personnel or their spouses in USA showed a small
but significant increase in the risk of cancer prostate
in vasectomised men27,41. In the Nurses Health Study
involving 14,607 vasectomised men and age matched
controls, the RR was 1.56 (CI 1.0-2.4). In the Health
Professionals follow up study data on 10,005 vasectomised
men and 37, 800 age matched controls were compared;
the RR was 1.66 (95% CI 1.25 - 2.21). Data from
another study in USA (involving the general population
availing the Kaiser Permanente Medical Care Programme)
men were either similar to or lower than those reported
in the control groups. There is no evidence of any
increase in autoimmune diseases or urinary tract morbidities
in vasectomised men14"20,23.
Two large record linkage
studies from USA17-18 and one community-based case
control study from China21 have shown that vasec
tomised men had lower age specific morbidity and
mortality rates than the control group. In one US study18
and the study in China21, the difference was due to
reduced CVD morbidity and mortality rates in men who
had undergone vasectomy. In the other US study the
reduction was due to lower malignancy rates17.
on 5119 vasectomised men and 15,357 controls showed
In the UK and USA most men who underwent
that the RR was 1.0 (95% CI 0.7-1.6)42. The Oxford
vasectomy in the seventies were 'elitist' health profess
record linkage study reported RR of 0.44 (95 % CI 0.0-
4.0) in a comparison of 13,246 vasectomised men and
22196 controls19.
ionals,
their spouses or 'health conscious* persons. It
has been suggested that the observed lower age specific
morbidity and mortality rates might at least in part be
A review in 1993 by the National Institutes of
due to the 'self selection' bias. 'Healthier' persons with
Health, USA and WHO of all the available data (both
healthier life styles might have undergone vasectomy
published and unpublished) on cancer prostate in vasec
and hence had lower morbidity and mortality rates. It
tomised men, endorsed the earlier WHO Expert Commit
is, however, difficult to define *healthy person' and
tee^ conclusion that there is no biological mechanism
'health conscious behaviour*
to explain the association between cancer prostate and
parameters. Hence proof for the hypothesis
vasectomy and a causal relationship between the two
lower morbidity rates could be attributed to these
is unlikely. The Expert Group noted that there was no
behavioural patterns remain elusive.
consistency between reports and the reported associa
tions were weak;
hence there was no basis to change
clinical and public health practices regarding vasecto
my. The Group recommended that studies should be
taken up in countries like India and China where the
prevalence of cancer prostate is low43. The ICMR has
initiated a hospital-based case control study to explore
the association, if any, between cancer prostate and
vasectomy in India. India will be one of the countries
participating in the proposed WHO multicountry study
on evaluation of the risk of cancer prostate in vasecto
mised men.
that the
In developing countries like China such a self
selection bias is unlikely. The fact that even in China
the vasectomised men have lower age specific morbidity
and mortality rates is,
therefore,
a very interesting
observation. Whether this beneficial effect on CVD
could be due to the freedom from anxiety over unwanted
pregnancies or stresses inevitable to the problems of
bringing up a large family within the existent resource
constraints in developing countries, is not known. Studies
need to be undertaken to explore whether similar find
ings are present in other developing countries like India.
Whatever may be the reason for the observed beneficial
Overall Morbidity and Mortality Rates
effect,
the association if found consistently, becomes
important in view of the fact that health benefits of
Record linkage studies on morbidity and mortality
vasectomy have to be weighed against the risks and an
men have been carried out
assessment regarding the long-term safety of vasectomy
rates
in
vasectomised
mainly in the UK and the USA14"20. During the last
96
in readily measurable
has to be made.
It is expected that in about
Needs of the Family Welfare Programme in India
The ideal contraceptive totally free of risks does
not e.Jst and is unlikely to be discovered in the near
future. In view of the ease, safety, low cost and feasi
bility in the primary health care set-up vasectomy is
an eminently suitable permanent method of contracep
tion in India. The Government of India is making
specific efforts to popularise vasectomy.
two years this study
will provide preliminary data on the magnitude of the
long-term risks and benefits associated with vasectomy
in men beyond 50 years of age. Based on these data
further studies can be planned and a balanced assess
ment of long-term health consequences of vasectomy
could be presented to policy makers, physicians and
potential clientele, so that they could make an informed
choice based on Indian data.
The conflicting publications on the long-term health
References:
consequences of vasectomy and ensuing debate have to
1.
Liskin, L., Benoit, E. and Blackburn, R. Vasectomy: New
opportunities. Popul Rep (D) No. 5: 1, 1992.
2.
Family "Welfare Programme in India : Year Book 1990-91
Department of Family Welfare, Ministry of Health and Family
Welfare, New Delhi. 1991, p.164.
3.
ICMR Task Force : Report of the Collaborative Study on
Sequelae of Tubal Sterilisation. Indian Council of Medical
Research, New Delhi, 1982.
4.
Naik, V.K., Thakur, A.N., Sheth, A.R., Joshi, U.M., Rao,
S.S., Pardanani, D.S., Kulsreshtha, J.K. and Handa, R.K.
The effect of vasectomy on pitutary-gonadal function in man.
J Reprod Fertil 48 : 441, 1976.
5.
Devi, P.K., Joshi, U.M., Moodbidri, S.B., Naik, V.K., Susheela,
P.S. and Sheth, A.R. Long term effects of vasectomy on the
pituitary-gonadal axis. Indian J Med Res 66: 591, 1977.
6.
Kobrinsky, N.L., Winter, J.S.D., Reyes, F.I. and Faimcn, C.
Endocrine effects of vasectomy in man. Fertil Steril 27: 152,
1976.
on risks and benefits.
7.
Ongoing ICMR Research Studies and Future Research
Plans
Thakur, A.N., Sheth, A.R., Rao, S.S. and Thacker, P.V.
Effectofvasectomy on prostalic function. Contraception. 7J.*155,
1975.
8.
Naik, V.K., Joshi, U.M. and Sheth, A.R. Long-term effects
of vasectomy on prostate function in man. J Reprod Fertil
58-289, 1980.
9.
Ansbacher, R. Humoral sperm antibodies : A ten year follow
up of vas ligated men. Fertil Steril 36: 222,
1981.
10.
Howard, P.J. and James, L.P. Immunological implications
of vasectomy. J Urol 109: 76, 1973.
11.
Alexander, N.J. and Clarkson, T.B. Vasectomy increases
the severity ofdiet induced atherosclerosis in Macacajascicularis
Science 201:533, 1978.
12.
Clarkson, T.B., Alexander, N.J. and Morgan, T.M.
Atherosclerosis of cynomolgus monkeys hyper and hypo
responsive to dietary cholestrol: Lack of effect of vasectomy.
Arleriosclerosis, 8: 488, 1988.
13.
World Health Organization Special Programme of Research,
Development and Research Training in Human Reproduction.
Sequelae of vasectomy - Report of a meeting. Int J Androl
5: 1, 1982.
be viewed in this context. It can be argued that even
if the risk of cancer prostate in vasectomised Indians
is similar to the highest reported in USA (RR of 1.7)
the number of vasectomised individuals affected by the
disease will be small, as there are only about 100,000
cases of cancer prostate in India. In contrast even a
small reduction in the magnitude of the risk of CVD
(RR of 0.7-0.9) would benefit a very large number of
men who had undergone vasectomy, because it is esti
mated that 23 million men suffer from CVD (hyper
tension and ischaemic heart disease). However,
this
argument may fail to satisfy the public because these
computations are not based on Indian data on the
magnitude of risks and benefits associated with vasec
tomy. It is therefore essential to find out the pattern
and
magnitude of the association between vasectomy
and these diseases and compute country specific data
The ICMR has recently initiated a comprehensive
hospital-based case control study to assess the risk of
CVD, CVA and cancers including cancer prostate in
vasectomised men. The "subjects” for the study are
married men beyond 50 years of age who are admitted
to the chosen hospital/ group ofhospitals with ischaemic
heart disease, cerebrovascular accidents, cancer prostate,
and cancers other than those of the genito-urinary tract.
The "controls” are age matched, married men admitted
to similar wards in the same hospital/group ofhospitals
within a month after admission of the "case” with
ocular problems such as cataract and glaucoma, ortho
paedic problems such as arthritis and fractures other
than pathological fractures, and chronic infections or
surgical problems other than those already listed.
97
14. Goldacre, M.J., Clarke, J.A., Heasman, M.A.and Vessey,
M.P. Follow up of vasectomy using medical record linkage.
Am J Epidemiol, 108: 176, 1978.
15. Walker, A. M.Jick, H.» Hunter, J. R., Danfbrd, A, and
Rothman, K J. Hospitalisation rates in vascctomizcd men.
J Am Med Assoc 245: 2315, 1981.
29. Biennial Report(1988-89). National Cancer Registry Programme,
Indian Council of Medical Research, New Delhi, 1992.
30. Strader, C.H., Weiss, N.S. and Dating, J.R. Vasectomy and
the incidence of testicular cancer. Am J Epidemiol 128: 56,
1988.
16. Pctitti, D.B., Klein, R., Kipp, H. and Friedman, G.D. Vasec
tomy and the incidence of hospitalized illness. J Urol 129:
760, 1983.
31. Cale, A.R.J., Farouk, M., Prescott, R.J. and Wallace, I.W.J.
Docs vasectomy accelerate testicular tumour? Importance of
testicular examinations before and after vasectomy. Br Med
J 300: 370, 1990.
17. Massey, F.J., Bernstein, G.S., O'Fallon, W.M., Schuman,
L.M., Coulson, A.H., C el al. Vasectomy and health: Results
from a large cohort study. J Am Med Assoc 252: 1023, 1984.
32. Yatani, R., Chigusa, I., Akazaki, K., Stemmcrmann, G.N.,
18. Giovanucci, E., Tosteson,T.D.,Speizer, F.E., Vessey, M.P.
and Colditz, G.A. A long-term study of mortality in men who
have undergone vasectomy. N Engl J Med 326: 1392, 1992.
19. Nicnhuis, H., Goldacrc, M., Seagroatt, V., Gill, L., and
Vessey, M. Incidence of disease after vasectomy : A record
linkage retrospective cohort study. Br Med J 304:143, 1992.
20. Schuman, L.M., Bernstien, G.S. and Kurland, L.T. Health
status of American men ― A study of post vasectomy
sequelae. J Clin Epidemiol 46: 719, 1993.
21. Guang-Hua, T.» Yu-Hui, Z., Yue-min, M., Lin, L., Kai, C.,
Jian, L., Guo-Hai, Z., I-Min, A., Dechun, L., Shu-Hua, Q.,
Farley, T.M.M., Rosenberg, M.J. and Strasser, T. Vasectomy
and health : Cardiovascular and other diseases following
vasectomy in Sichuan province, People's Republic of China.
Int J Epidemiol 17: 608, 1988.
22. Chi, I.C., Kong, S.K., Wilkens, L.R., Cho.A.J., Siemens,
A.J., Meng, K.H. and Higgins, J.E. Vasectomy and cardio
vascular deaths in Korean men : A community-based case
control study. Int J Epidemiol 19: 1113, 1990.
23. Chi, I.C., Ko, U.R., Wilkens, L.R., Chang, H.K. and
Nam, J. J. Vasectomy and non-fotal acute myocardial infarction:
A hospital-based case-control study in Seoul, Korea. Int J
Epidemiol 19: 32, 1990.
24. Indian Council fbr Medical Research. Long-term effects of
vasectomy, part I : Biochemical parameters. An ICMR Task
Force study on regulation of male fertility (surgical ap
proaches). Contraception 28: 423, 1983.
25. Luthra, U.K., Prabhakar A.K., Gupta, T.C. and Shah. B.
Preventive cardiology: Strategies for the nineties. In: Pre
ventive Cardiology : An Introduction. Ed. H.S.Wasir, Vikas
Publishing House, New Delhi, 1991, p.15.
26. Enas, A.E., Yusuf, S. and Mehta, J.L. Prevalence of
coronary artery disease in Asians. Am J Cardiol 70:945,1992.
27. Giovannucci, E., Ascherio, A., Rimm, E.B., Colditz, G.A.,
Stampfer, M.J. and Willett, W.C. A prospective cohort study
of vasectomy and prostate cancer in US men. J Am Med Assoc
269: 873, 1993.
28. Muir, C., Waterhouse, J., Mack, T., Powell, J., Whelan,
S., Smars, M. and Cassel, F. Cancer incidence in five
continents. IARC Sci Pub 88: 936, 1987.
98
Welsh, R.A. and Correa, P. Geographic pathology of latent
prostatic carcinoma. Int J Cancer 29: 611, 1982.
33. Farley,
Meirik, O., Mehta, S. and Waites, G.M.H.
The safety of vasectomy: Recent concerns. Bull WHO 71:
413, 1993.
34. Nomura, A.M.Y. and Kolonel, L.N. Prostate cancer : A
current perspective. Epidemiol Rev 13: 200, 1991.
35. Ross, R.K., Paganini-Hill,A. and Henderson, B.E. The etio
logy of prostate cancer. Prostate 4: 333, 1993.
36. Newell, G.R., Fueger, J.J., Spitz, M.R. and Babaian. R.J. A
case-control study of prostate cancer. Am J Epidemiol 130:
395, 1989.
37. Sidney, S. Vasectomy and risk of prostate cancer and benign
pro static hypertrophy. J Urol 138: 795, 1987.
38- Honda, G.D., Bernstein, L., Ross, R.K., Greenland, S.,
Gerkins, V. and Henderson, B .E. Vasectomy, cigarette smoking
and age at first sexual intercourse as risk factors for prostate
in middle aged men. Br J Cancer 57: 326, 1988.
39. Rosenberg, L., Palmer, J.R., Zaubcr, A.G., Warshauer,
M.E., Stolley, A.D. and Shapiro, S. Vasectomy and risk of
prostate cancer. Am J Epidemiol 132: 1051, 1990.
40. Mettlin, C., Natarajan, N. and Huben, R. Vasectomy and
prostate cancer risk. Am J Epidemiol 132: 1056, 1990.
41. Giovannucci, E.,Tosteson,T.D., Speizer, F.E., Ascherio, A.,
Vessey, M. and Colditz, G.A. A retrospective cohort study
of vasectomy and prostate cancer in US men. J Am Med Assoc
269: 878, 1993.
42. Sidney, S., Quesenberry, C.P. Jr,Sadler, M.C., Guess, H.A.,
Lydick, E.G. and Cattolica, E.V. Vasectomy and the risk of
prostate in a cohort of multiphasic health check up examinees:
Second report. Cancer Causes Control 2: 113, 1991.
43. Healy, B. Does vasectomy cause prostate cancer? J Am Med
Assoc 269: 2620, 1993.
This write-up is contributed by Dr. C.R. Ramachandran, Senior
Dy. Director-General and Dr. P. Ramachandran, Deputy DirectorGeneral (Sr. Grade), ICMR Hqrs, New Delhi.
ABSTRACTS
Some Research Projects Completed Recently
Ultrastructural changes in early leprosy:
days to 2 yr. Among the lymph nodes involved, cervical
A total of 70 clinically early, unclassifiable and
doubtful cases of leprosy with disease of less than 12
months duration and with upto five lesions were studied
to elicit fine structural changes in early lesions of
nodes were the commonest (66%), followed by the
axillary nodes (10%). Involvement of both cervical and
axillary lymph nodes was seen in 13 per cent and
generalized lymphadenopathy in 8 per cent of patients.
leprosy, to identify definite criteria for early diagnosis
Fine needle aspiration cytology (FNAC) showed
and understand the pathological mechanism involved in
reactive hyperplasia in 134 (67%), tuberculosis in 48
the development of early lesions in the leprosy.
(24%), lymphoma inlO (5%) and tumour in two. In six
All patients were subjected to skin biopsy. Light
patients FNAC was inconclusive.
microscopy revealed histologically developed granulomas
Of the 200 patients, 120 were subjected to surgical
in 18, indeterminate leprosy in 14 and no lepromatous
biopsy of the same lymph node and the FN AG diagnosis
changes in 38 subjects. Electron microscopy in 25
was compared with the histopathological diagnosis.
subjects
who
had
no
specific
changes
on
light
There were 74 patients with reactive hyperplasia, all of
microscopy, showed nonspecific inflammatory changes
whom
in 20 patients. Five patients revealed derangement in the
histopathology. Of the 28 patients of tuberculosis, 14 of
could
both
diagnosed
be
FNAC
by
and
fine structure of the dermal nerve twigs in the form of
Hodgkin's and 4 of non-Hodgkin's disease (diagnosed
oedema of the nerve fiber with separation of Schwaan
by histopathology) only 20, 8 and 2 patients were
cells and swelling of the axons and splitting of myelin
diagnosed by FNAC, giving accuracy rates of 71.4, 57.1
sheath. In addition, fragments of electron dense material
and
per
cent
respectively.
which could be of bacillary origin were also found within
cytodiagnosis
was
obtained
the Schwann cell cytoplasm.
cytology in 104 of 120 patients giving an accuracy rate of
It is concluded that as the electron microscopy of
50
a
correct
aspiration
biopsy
Thus,
by
86.6 per cent.
patients with negative histological finding on light
In four patients of tuberculosis lymphadenitis and
microscopy showed specific changes of leprosy in only
two of Hodgkin's disease
FNAC was inconclusive
20 per cent of subjects, it is not of significant use to
necessitating
an
confirm the disease.
whereas in four patients of histopathologicaly proven
R.S. Misra
Department of Dermatology,"
Leprology and STD
Safdaijung Hospital,
New Delhi.
biopsy
tuberculous
adenitis
lymphoma
cytology
for
and
diagnosis,
etiological
of
two
revealed
non-Hodgkin's
evidence
of
reactive
hyperplasia. In four patients of Hodgkin's disease, there
were
false
positive
results
on
FNAC,
two
being
diagnosed as tuberculous adenitis and two as red cell
tumour.
It is thus concluded that aspiration cytology is, by
Role of fine needle aspiration as.an effective diagnostic
and large a simple, safe, rapid and fairly accurate
tool in lymphadenitis affecting children:
procedure.
It
is
a
low
cost
outpatient
technique
requiring no hospitalization or anaesthesia. It has a
The study was carried out in 200 children (132 boys
and 68 girls) in the age group of one month to 12 years
potential of being adopted as a
routine screening
investigation in palpable and accessible swellings.
with lymphadenopathy to determine the etiopathogenesis
of lymphadenitis and evaluate the accuracy of fine
B. Lakshmanan
needle aspriation technique as a diagnostic aid. The
C.H. Gidvani
major presenting symptoms were loss of appetite and
Department of Paediatrics
weight (73%), fever (60%), swelling in the neck (55%)
Armed Forces Medical College,
and cough (36%); duration of symptoms varied from 3
Pune.
99
ICMR NEWS
The
following
of
meetings
various
technical
committees/groups of the Council were held at New
Delhi:
on Population and Development at Cairo (September 3-
13, 1994).
Dr. Jayashree Nandi, Research Officer, National
Expert Group on
August 17-18, 1994
Goitrogens.
Institute of Virology (NIV), Pune, participated in the
VIII MRC AIDS Workshop at Manchester (September
4-7, 1994).
Central Ethical Committee
August 18, 1994
Toxicological Review Panel
August 18, 1994
Expert Group on Assisted
September 12, 1994
Dr. Aruna De wan, Dy. Director, National Institute
of Occupational Health, Ahmedabad, participated in
the VII meeting of the IPCS/INTOX Poisons Centre
Working Group (INTOX-7) at Sao Paulo (September 59, 1994).
Reproductive Technology
Expert Group on Earthquake
September 13, 1994
Disaster of Marathwada.
Dr. M.S. Malhotra and Dr. Aruna Srivastava,
Senior Research Officers, Malaria Research Centre,
Delhi, participated in the International Workshop on
Participation of ICMR Scientists in Scientific Events:
Health and Environment at Colombo (September 5-10,
1994).
Dr.
K.
N Panicker and
Dr. S. P. Pani, Dy.
Directors, Vector Control Research Centre (VCRC),
Pondicherry and Dr. V. Kumaraswami, Asstt. Director,
Tuberculosis Research Centre, Madras, participated in
the Informal Consultation Meeting on the development
of new strategies for the control of lymphatic filariasis at
Dr.
Leela
Raman,
Dy.
Director (Sr.
Grade),
Institute of Nutrition (NIN), Hyderabad,
participated in the International Nutrition Program
Seminars at Ithacha, New York (August 22-30, 1994).
Dr.
K.N.
Dy.
Panicker,
Director,
VCRC.
Kalyan
Director,
Banerjee,
NIV,
Pune,
on Orthopoxvirus Infection at Geneva (September 9,
1994).
Dr.
delivered
Penang, (August 20-28, 1994).
National
Dr.
participated in a meeting of WHO Ad-hoc Committee
G.V.
a
Satyavati,
special
Director-General,
ICMR,
"Whither
Medical
on
lecture
Research in India" at the A.P. Academy of Sciences,
Hyderabad where she was honoured as a distinguished
scientist
12,
(September
1994).
She
delivered
the
inaugural address at the symposium on Laboratory
Animal Resource Development Experimentation and
Welfare —Which Way to Go? at Hyderabad (September
Pondicherry, Participated in the WHO meeting of the
13, 1994). Dr. Satyavati also delivered the Decennary
Control of Tropical Diseases at Geneva (September 1-2,
Oration
1994).
"Medical
Dr.
G.
Ghafoorunissa.
Dy.
Director,
NIN,
Hyderabad, participated in the UNESCO/COSTAM/
of the
JSS
Research
Medical
College,
Medical
vis-a-vis
Mysore on
Education in
IndiaM at Mysore (September 14, 1994).
Hindi Day Celebrations:
SFRR-Asia Workshop on Nutrition, Lipids, Health
and Disease at Penang as also in the Oils and Fats
International
Congress
1994
at
Kuala
Lumpur
As part of Hindi Day celebrations by the ICMR
Headquarters,
a
popular
lecture
(in
Hindi)
on
Treatment of Gall Stones was delivered on September
(September 1-3 and 5-8, 1994 respectively).
13, 1994 by Dr.' R.K. Tandon, Professor and Head,
Dr.
Veena
Shatrugna,
Asstt.
Director,
NIN,
Hyderabad, participated in the International Conference
100
Department of Gastroenterology, All India Institute of
Medical Sciences, New Delhi.
ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES
Sy mposium/Seminar/Workshop/
Course/Conference
•
1
Date & Place
Contact Address
National Workshop on Neuroepidemiology.
September 1-4, 1994;
(at Bangalore)
Dr. M. Gourie-Devi, Organising Secretary of the
Workshop, Department of Neurology, National Insti
tute of Mental Health and Neurosciences, Bangalore.
XII Annual Conference of ISMS on Evalu
ation Technology in Medical Education
and Health Care Delivery System.
September 5-7. 1994;
(at Sevagram)
Dr. N.K. Tyagi, Organising Secretary of the
Conference, M.G. Institute of Medical Sci
ences, Sevagram, Ward ha.
Continuing Medical Education in Psychiatry.
September 10-11, 1994;
(at Manipal)
Dr.P.S.V.N. Sharma, Organising Secretary,4th Annual
Conference of the Indian Psychiatry Society,
Department of Psychiatry. Kasturba Medical
College, Manipal.
Symposium on Complex Carbohydrates.
September 15-16, 1994;
(at Roorkee)
Dr. Ritu Barthwal, Organising Secretary of the Sym
posium, Department of Biosciences and Biotechno
logy, University of Roorkee, Roorkee.
Satellite Symposium on Free Radicals in Biology.
September 15-17, 1994;
(at Chandigarh)
Dr. N.K. Ganguly, Organising Secretary of the
Symposium, Department of Experimental Medicine
and Biotechnology, Postgraduate Institute of
Medical Education and Research. Chandigarh.
VI National Symposium on Ultrasonics and
One Day Workshop on Ultrasound in Medicine.
September 15-17, 1994;
(At Tirupati)
Prof. L. Rama Murthy. Convenor, NSU-VI-94,
Department of Physics. S.V. University. Tirupati.
National Update on Nutrition in Children.
September 24-25, 1994;
(at New Delhi)
Dr. H.P.S. Sachdev. Secretary. Indian Academy of
Pediatrics. Department of Pediatrics, Maulana Azad
Medical College, New Delhi.
International Conference on Molecular and
Metabolic Endocrinology and Contraceptive
Technology.
September 26-27, 1994;
(at Madras)
Dr. M. Michael Aruldhas, Organising Secretary.
Silver Jubilee International Conference. Department
of Endocrinology, Dr. A.L. Mudaliar Postgraduate
Institute of Basic Medical Sciences, Madras.
M ICON-Internationl* 94.
November 9-12, 1994;
(at Mysore)
Dr. R. Shankaran, Chairperson of the Organising
Committee, MJCON-lnternationar94. Defence Food
Research Laboratory, Siddhartha Nagar, Mysore.
Ill International Conference on DNA Finger
printing.
December 13-16, 1994：
(at Hyderabad)
Dr. Lalji Singh, Organising Secretary of the
Conference, Centre for Cellular and Molecular
Biology, Hyderabad
International Symposium on Atherosclerosis,
Thrombosis and Transfusion Medicine.
December 15-20, 1994;
(at Bombay)
Dr. D. Mohanty, Director. Institute of Immuno
haematology, Parel, Bombay.
101
；
LIBRARY
AND
卒\ DOCUMENTATION J
COUNCILS TRAINING PROGRAMMES
Reproductive Biology
Training Course on Air Pollution Monitoring and
At the Institute for Research in Reproduction, Bombay:
Risk Assessment (October 19-25, 1994).
...
Workshop on Gynaecologic Cytology and Immuno
...
Training Course in
Pesticide Residue Analysis
(December 5-9, 1994).
cytochemistry (September 26-October 1, 1994).
Nutrition
Laboratory Animal Technology
At the National Institute of Nutrition, Hyderabad:
At the Laboratory Animal Information Service Centre,
National Institute of Nutrition, Hyderabad:
...
Annual Training Course in Nutrition (December I,
...
1994-February 28, 1995).
Training Course for Laboratory Animal Super
visors (September 12- December 10, 1994).
Occupational Health
Haematology
At the
National Institute of Occupational Health,
At the Institute of Immunohaematology, Bombay:
Ahmedabad:
...
Orientation Course on Occupational Health for
Industrial
Medical
Officers (September
...
Training Course in Blood Group .Serology and
Blood Bank Methodology for Medical Officers
19-24,
(August 9-October 7, 1994).
1994).
Editorial Board
Chairperson
Members
Dr. G.V. Satyavati
Dr. Badri N. Saxena
Director-General
Dr. C.R. Ramachandran
Editor
Dr. N. Medappa
Printed and Published by Shri J.N. Mathur for the Indian Council of Medical Research, New Delhi
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