Infertility as inevitable: chronic lifestyles, temporal inevitability and the making of abnormal bodies in India.

In seeking to explore the meaning of chronic and chronicity, the association with infertility is neither immediate nor evident. However, this paper explores this relationship by analyzing the idea of infertility in relation to chronicity. In the linkages that come forth the idea of chronic lifestyle emerging from certain ways of being and living, as well the imaginings associated with the chronic body become important nodes of exploring the relationship between infertility and chronicity. Most importantly, the role that time plays in marking the chronic state is seen to be especially potent in the practice of infertility treatment, and the narratives that emerge around its temporal inevitability. The rhetoric that marks the diagnosis and prescription of treatment is often based on the identification of the body as susceptible to reproductive decline and failure, due to the contingencies of modern living. This often translates into a more sustained involvement with ARTs, which may or may not fulfil the required desire for a child. In this paper I seek to analyse the ways in which practitioners of infertility medicine create an image of an affliction that borders on chronicity. In the process, I question the idea of both chronic diseases and chronicity by looking at how illness is imagined in narratives that IVF specialists create in public, and through the idea of a cure for infertility. By analysing data collected through ethnographic fieldwork, this paper aims to build on the idea of the chronic as inevitable within clinical discourse and practice.

Outliers and Rogue Doctors: Manufacturing "Anxiety" Around Older Mothers in India.

In this article I focus on media narratives on older women bearing and birthing infants through the intervention of assisted reproductive technologies (ART) in rural north India. I suggest that their portrayal as "outliers" within popular media narratives is gendered, and connected in particular to: the fear of older women past their reproductive prime becoming pregnant and birthing children through ART; the figure of the "rogue doctor," or the emergence of counter narratives around ART and its practitioners; and, the effort to quell anxieties around ART use amongst older women through the use of legitimating tropes such as conjugality.

Conceptualizing aged reproduction: genetic connectedness, son preference and assisted reproduction in North India.

In this paper, I explore the narratives on the administration of assisted reproductive technology (ART) treatments amongst ageing men and women who are past their 'reproductive prime'. I use the phrase 'past their reproductive prime' with caution as ART has the capability to resurrect the desire, quest and conception of children amongst these ageing women and men. In rural agrarian Haryana in North India, ART panders to, and provides, potent narratives for perpetuation of the patrilineage for genetic continuity through the male line. The administration of ART treatments to this particular demographic is undertaken through the 'operation' of two particular forms of discourse: the desire for genetic perpetuity, and the pursuit of sons. In this enterprise, the aged pregnant body becomes an important trope of resurrecting childless marriages, evidenced by the secrecy surrounding the use of donated sperm, and the open rejection of adoption. Through an exploration of conceptualizations of pregnancy, age and legislation in India, I present the argument that ART supports the pursuit of genetic connectedness by resurrecting the social importance of genetic connectedness through sons and the pregnant wife. In this paper, I purposely engage with elements of the study of kinship and family in South Asia to undertake an analysis of how ART is used as part of a larger social narrative around conception and pregnancy amongst older married couples.

Ageing and Reproductive Decline in Assisted Reproductive Technologies in India: Mapping the 'Management' of Eggs and Wombs.

In this paper, I discuss the ethical underpinnings to the anthropological analysis of age and reproductive decline in the 'management' of infertility, by suggesting that assisted reproductive technologies (ART) 'use' age and reproductive decline to further endanger women's bodies by subjecting it to disaggregation into parts that do not belong to them anymore. Here, the category of age becomes a malleable concept to manipulate women seeking fertility management. In ethnographic findings from two Indian ART clinics, amongst women aged between 20 and 35 years visiting an IVF/ART clinic in Hyderabad city in South India, and women above 50 years of age visiting an IVF/ART clinic in Hisar in North India-reproductive bodies are similarly disaggregated. In case of younger women, the treatment is fixated on rescuing eggs that may be in 'decline', and in case of older women, the aim is to engineer a viable pregnancy. Thus, the constant focus on eggs and wombs in infertility treatment creates a body that is not only not whole but also completely without agency. Age becomes a category that has rhetorical value to 'push' or persuade women into particular forms of fertility management through infertility medicine. I undertake a problematization of the egg and the uterus through the identification of the recurring motif of the menstrual cycle within IVF treatment to suggest that bodily holism is not part of ART discourse that unethically thrives on promoting technological intrusions to promote its use and normalization.

ARTs and the problematic conceptualisation of declining reproduction.

The routinisation of assisted reproduction in India has led to its proliferation and the easy identification of infertility. However, clinical and popular discourse tends to focus primarily on age-related deficiencies in reproduction. Here, both the "dangers" of declining reproduction as well as the facilitation of delayed reproduction are areas of focus and eulogisation. Bringing together the diverse elements of the medico-social conversation, the aim of this commentary is to examine the ways in which the ARTs are used to make sense of declining reproduction.

Multi-antigen and antibody assays (SEVA TB ELISA) for the diagnosis of tuberculous pleural effusion.

OBJECTIVE: Prospective evaluation of inhouse developed SEVA TB ELISA using cocktail of Mycobacterial antigens ES-31 and EST-6 (containing ES-38 and ES-41) and their specific antibodies in the diagnosis of Tuberculous pleural effusion was done in a tertiary care hospital. METHODS: Detection of circulating free and immune-complexed (IC) antigens and antibody by sandwich and indirect peroxidase ELISA respectively was done in pleural fluid and sera specimens. Total 33 patients with pleural effusion, including 24 patients diagnosed as tuberculous pleural effusion based on clinico-radiological, microbiological and biochemical profile (protein, LDH and ADA) of pleural effusion and nine patients with non-tuberculous pleural effusion, were studied. RESULTS: Pleural fluid showing either antigen or immune-complexed antigen or antibody positive was considered as ELISA positive for tuberculous pleural effusion. Multi antigen and antibody assay (SEVATB ELISA) showed 100% specificity and 83% sensitivity in pleural fluid while 78% specificity and 92% sensitivity in serum of tuberculous pleuritis patients. CONCLUSION: This study showed usefulness of SEVATB ELISA, using cocktail of ES-31 and EST-6 antigens and their antibodies for antibody and antigen detection respectively in analysis of either sera or pleural fluid samples of suspected tuberculous pleuritis patients as an adjunct test to clinical diagnosis.

Improved laboratory diagnosis of tuberculosis--the Indian experience.

Tuberculosis (TB) is the leading cause of death worldwide attributable to a single infectious disease agent. India has more new TB cases annually than any other country. In 2008, India accounted for a fifth of the estimated 9.4 million TB cases globally. There is an overwhelming need for improving TB diagnostics in India through the use of cost effective, patient-friendly methods appropriate to different tiers of the country health system. Substantial progress has been made in India in the field of TB diagnosis and serious efforts have been made to herald the development of diagnostic tests for pulmonary TB, extra pulmonary TB and MDR-TB. Diverse approaches have been attempted towards improving smear microscopy, rapid culture and for differentiation between the Mycobacterium tuberculosis complex and non-tuberculous mycobacteria. Several laboratories have developed in-house PCR assays for diagnosing TB with high accuracy. Approaches for distinguishing M. tuberculosis and/or Mycobacterium bovis infection and disseminated Mycobacterium avium complex infection in HIV-AIDS patients have also been described. Serological tests to detect antigens or antibodies to M. tuberculosis specific components by using cocktails of Excretory/Secretory protein antigens, Ag85 complex antigens, Hsp 65 antigen, RD1 antigens and Rapid Reverse Line Blot Hybridization assays to detect MDR-TB (mutations to rifampicin, isoniazid and streptomycin) have also been developed. Other methods like measurement of adenosine deaminase activity and use of luciferase reporter phages have also been explored for TB diagnosis. These advances in the Indian context are detailed in the present chapter. The validation and application of these methods in laboratory and public health settings is likely to result in improved TB diagnosis and contribute to effective disease management in India.

A sensitive and specific ES-31 antigen detection based fluorometric assay for confirmation of Mycobacterium tuberculosis in cell culture.

Confirmation of presence of M. tuberculosis bacilli on microscopic examination is very important in diagnosis of tuberculosis. The present study was undertaken to find the usefulness of mycobacterial ES-31 serine protease as a marker to detect tuberculosis bacilli using fluorescein isothiocyanate conjugated anti-ES-31 serine protease antibody. This immunofluorescence method was compared with Ziehl-Neelsen and auramine-O staining methods for detection of tuberculosis bacilli. Slides were prepared for each serially diluted tuberculosis H37Ra bacilli (1 x 10(7) bacilli/ml to 5 bacilli/ml). Slides for each dilution group were stained by ZN method, auramine-O and immunostaining methods using fluorescein isothiocyanate conjugated anti-ES-31 serine protease antibody. ZN staining method showed efficacy for detection of M. tuberculosis H37Ra upto 1 x 10(4) bacilli/ml while auramine-O method showed upto 1 x 10(2) bacilli/ml. The presence of bacilli was indicated by green fluorescence on immunostaining using anti-ES-31 antibody conjugate and this method was effective upto 10 bacilli/ml. The slides which were negative for ZN (1 x 10(3) cells/ml) and auramine-O (100 cells/ml) method showed positivity on restaining with immunofluorescent staining method. The results of this preliminary study showed that immunofluorescent staining method using specific anti-ES-31 antibody conjugate was more sensitive for detection of tuberculosis bacilli than ZN and auramine-O methods in samples of laboratory strain. The utility of this method will be studied further in clinical specimens.

Effect of HIV protease inhibitors and Orlistat on mycobacterial ES-31 serine protease, a potential drug target in Mycobacterium tuberculosis.

BACKGROUND: Mycobacterial excretory secretory-31 (SEVA TB ES-31) antigen is shown to possess protease and lipase activities. AIM: To study the effect of commonly used HIV-protease inhibitors and lipase inhibitor Orlistat if any on mycobacterial ES-31 serine protease in vitro enzyme activity and on the growth of M.tb H37Ra bacilli in axenic culture. METHODS: Effect of HIV-protease inhibitors namely Ritonavir, Lopinavir and Indinavir and Orlistat on protease activity of ES-31 was assessed using azocasein assay and on bacillary growth in axenic culture of Mycobacterium tuberculosis H37Ra. The concentration of ES-31 antigen in culture filtrate was determined by sandwich peroxidase ELISA using anti ES-31 antibody and the growth of bacilli by CFU count. RESULTS: HIV-protease inhibitors such as Ritonavir, Lopinavir and Indinavir and lipase inhibitor Orlistat inhibited serine protease activity by 41.3 - 69.7% in vitro. These inhibitors also showed decreased bacterial growth in axenic culture and further confirmed by decreased concentration of ES-31 serine protease secretion in the culture fluid. Ritonavir showed maximum inhibition of 77% on the growth of the bacilli in axenic culture while anti obesity drug Orlistat showed 61% inhibition. CONCLUSION: SEVA TB ES-31 with serine protease and lipase activities may be a potential drug target in tuberculosis management.

Detection of circulating free and immune-complexed antigen in pulmonary tuberculosis using cocktail of antibodies to mycobacterium tuberculosis excretory secretory antigens by peroxidase enzyme immunoassay.

BACKGROUND: Decreased sensitivity has been a limiting factor of antigen assay for detection of tuberculosis. Assay of more than one antigen may improve sensitivity of an assay. AIM: To develop a simple, rapid and less-expensive serodiagnostic method compared to culture method for Pulmonary Tuberculosis. METHOD: A cocktail of affinity purified antibodies against Mycobacterium tuberculosis H37Ra antigens (SEVA TB ES-31, ES-43 and EST-6) was explored for detection of circulating free and Immune-Complexed (IC) cocktail antigen by microtitre plate Peroxidase sandwich ELISA. The assay was evaluated in 27 clinical sera of sputum acid fast bacilli (AFB) positive and 10 AFB negative but anti-tuberculosis therapy responded pulmonary tuberculosis patients and 20 normal sera as controls. RESULTS: Assay of cocktail antigen showed marginal improvement in sensitivity compared to assay of ES-31 antigen alone. The assay for circulating free cocktail antigen showed a sensitivity of 77.7% for AFB positive cases and 70% for AFB negative cases compared to assay of ES-31 antigen with sensitivity of 74% and 70% respectively. The assay for IC-cocktail antigen showed sensitivity of 77.7% for AFB positive and 80% for AFB negative cases compared to assay of ICES-31 antigen with sensitivity of 77% and 70% respectively. Specificity of antigen assay was found to be 90%. Detection of IC-antigen as adjunct assay improved the sensitivity of detection in AFB-ve but ATT responded cases. Peroxidase enzyme immunoassay of cocktail antigen showed a sensitivity of detection of 0.25 microg/ml and levels of free and IC cocktail antigens were 1.70 +/- 1.04 and 1.13 +/- 0.047 microg/ml in AFB positive patients' sera. CONCLUSIONS: Peroxidase enzyme immunoassay for circulating antigen was found to be a useful serodiagnostic assay and in particular in AFB -ve cases responding to ATT.

Inhibition of Mycobacterium tuberculosis secretory serine protease blocks bacterial multiplication both in axenic culture and in human macrophages.

To study the possible importance of mycobacterial ES-31 serine protease for bacterial cell growth, the effect of serine and metalloprotease inhibitors, anti-tubercular drugs such as isoniazid and anti-ES-31 antibody, was evaluated on mycobacterial ES-31 serine protease in vitro and on bacilli in axenic and macrophage cultures. Serine protease inhibitors such as pefabloc, 3,4 dichloroisocoumarin, phenyl methyl sulfonyl fluoride (PMSF) and metalloprotease inhibitors such as ethylene diamine tetracetic acid (EDTA) and 1,10 phenanthroline inhibited 65-92% serine protease activity in vitro. Isoniazid showed 95% inhibition on mycobacterial ES-31 serine protease. These inhibitors also showed decreased bacterial growth in axenic culture and inhibition was further confirmed by a decreased amount of ES-31 serine protease in culture filtrate. In human macrophage culture, highly inhibitory pefabloc, 1,10 phenanthroline and isoniazid inhibited infectivity of virulent as well as avirulent M. tuberculosis bacilli to macrophages. It was observed that addition of mycobacterial ES-31 serine protease to macrophage culture enhanced the entry of bacilli and their multiplication in human macrophages. However, the addition of anti-ES-31 serine protease antibody strongly inhibited the mycobacterial growth as observed by decreased CFU count, showing the importance of mycobacterial ES-31 serine protease for entry of bacilli and their multiplication.