Introduction

• Know as fetal gene therapy, gene transplant surgery, and fetal gene transfer

• Has the potential to correct the genetic defects in a preborn child before the mother gives
birth

• Traditional gene therapy have focused on correcting genetic defects in children and adults

• Biggest challenges of this type of gene therapy has been targeting the correct area of the
body without generating a response by the immune system

• New genes are recognized and attacked by the body’s immune system as a foreign
substance

• Prenatal gene therapy has the potential to eliminate this problem by targeting the body
before the immune system is fully developed
 Fetal gene Therapy
Prenatal or in utero gene therapy
This kind of treatment might represent a suitable therapeutic possibility for pregnant women
in whose fetus a hereditary disorder has been diagnosed and who do not wish to undergo
therapeutic abortion.

Targets genetic diseases which require lifelong correction

The concept of fetal gene therapy is based on the following aims:

• avoiding early-onset manifestation of life-threatening genetic conditions
• achieving permanent correction of such diseases by stable transduction of
relevant fetal progenitor cell populations
• Avoiding immune reactions against the therapeutic vector and transgene by
induction of tolerance.
 First proofs of principle for therapeutic in utero
gene application
• First successful therapeutic application of gene transfer in
utero was carried out in 2003 by Seppen et al.
• This was achieved by direct injection of a lentiviral vector
expressing the human bilirubin UDP-glucuronyltransferase
(UGT1A1) gene under control of the phosphoglycerate
kinase promoter into the liver of Gunn rat fetuses.
Injection of therapeutic nucleic acids, under echographic
guidance, directly into the fetus during intrauterine life.

Several small animal models of human disease

Crigler-Najjar disease (the Gunn rat, with a defect in UDP-
glucuronosyltransferase enzyme),
Leber’s congenital amaurosis (the RPE65 knock-out mouse),
Pompe’s disease (α-glucosidase knock-out mouse),
Hemophilia B (Factor IX knock-out mouse), in addition to
fetuses of larger animals, mostly sheep.
Successful Therapeutic Applications
 Benefits of prenatal gene therapy
• Provides early phenotypic correction, reducing or avoiding
otherwise devastating effects of genetic disease
• Demonstration of long-term postnatal therapeutic protein
production
• Tolerance to the transgenic protein can be induced by in
utero expression
“Although fetal gene therapy will not replace postnatal gene
therapy, it is essentially a preventive approach to the
management of otherwise predominantly incurable diseases and
would therefore – if successful and safe – be most effectively
conducted in conjunction with prenatal screening
programmes.”
 Progress in Prenatal Gene Therapy
• Disparity between species must be taken into account when
considering administration of human fetal gene therapy
• Minimally invasive methods of ultrasound guided gene
delivery are being devised in large animal models
Prenatal/fetal gene therapy with case study

Tay Sachs Disease

 What is Tay-Sachs?
• Tay-Sachs diseases causes a progressive
deterioration of nerve cells and of mental
and physical abilities that begins around six
months of age.

• The disease occurs when harmful quantities

of cell membrane components known as
gangliosides accumulate in the brain’s
nerve cells
 What is Tay-Sachs?
• A fatal genetic disorder
• Most commonly occurring
in children
• Results in progressive
destruction of the nervous
system
• Caused by the absence of a vital
enzyme called hexosaminidase-
A (Hex-A).
What is Tay-Sachs?
 Cell
damage Without
and death Hex- A

Especially A fatty
in nerve substanc
cells of the e GM2
brain ganglosid
e
accumulate

abnormally
 What is Tay-Sachs?
• Autosomal recessive storage
lipid disorder
• High incidence among Ashkanazi Jews,
Cajuns, French Canadians
• Lack of enzyme, Hexosaminidase A
• Leads to accumulation of
GM2 ganglioside in the neurons
How do people inherit Tay-Sachs
disease?
• This condition is inherited in an autosomal
recessive pattern, which means both copies of
the gene in each cell have mutations

• The parents of an individual with an

autosomal recessive condition each carry one
copy of the mutated gene, but they typically
do not show signs and symptoms of the
condition.
 Symptoms of Tay-Sachs

• Infants initially appear healthy;

symptoms appear not before 6 months of age
• Development begins to slow
• Loss of motor skills, mental functions
• Child becomes blind, deaf, paralyzed,
mentally retarded, and non-responsive
• Fatal, usually by age 4
There are three forms of Tay-Sachs disease: infantile, juvenile and late onset/adult.

Infantile form In the most common and severe form, called infantile form, an
infant typically begins showing signs and symptoms by about 3 to 6 months of age.
Survival is usually only a few years. Signs and symptoms can include:

• Exaggerated startle response when the baby hears loud noises

• "Cherry-red" spots in the eyes
• Loss of motor skills, including turning over, crawling and sitting up
• Muscle weakness, progressing to paralysis
• Movement problems
• Seizures
• Vision loss and blindness
• Hearing loss and deafness
• Problems swallowing
• Loss of mental functions and a lack of response to surroundings
• Growth in head size (progressive macrocephaly)
Juvenile form

The juvenile form of Tay-Sachs disease is less common. Signs and

symptoms vary in severity and begin in childhood. Survival is
typically into the teen years. Signs and symptoms can include:

• Behavior problems
• Gradual loss of skills and movement control
• Frequent respiratory infections
• Slow loss of vision and speech
• Decline in mental function and responsiveness
• Seizures
Last onset/adult form

This is a rare and less severe form with signs and symptoms beginning
in late childhood to adulthood. Severity of symptoms varies greatly, and
this form does not always impact life expectancy. Signs and symptoms
progress slowly and can include:

• Muscle weakness
• Clumsiness and loss of coordination
• Tremors and muscle spasms
• Loss of the ability to walk
• Problems speaking and swallowing
• Psychiatric disorders
• Sometimes loss of mental function
 Classical Diagnosis

• Appearance of
aforementioned symptoms
• “Cherry-red” spot on
eyes, caused by lipid-
laden ganglion cells
• Larger startle reflex
to
noise 1970, Tay-Sachs
• Before
could not be diagnosed at
birth
 Classical Testing
• In 1969, researchers discovered
the biochemical basis for the disease
• Michael Kaback of JHU created
an enzyme assay to test for
heterozygotes
• Detects individuals with lower levels of
Hex-A
• Can detect all mutations, but
with some inconclusive results
 Classical Treatment

• There is currently no treatment for Tay-

Sachs disease
• Supportive treatment
• Anti-seizure medicine
• Feeding tube
• Proper nutrition, hydration
 Genetic Testing
• Caused mutations in both
alleles
by of HEXA gene on
chromosome 15. Exact location
(15q23- q24) determined in
1990.

• PCR tests for actual mutations.

Gives definite results, but only
for known mutants.
 Treatment
All in experimental stages
• Gene therapy
1. Replace defective HEXA genes.
2. Difficult to transport genes to neurons.
• Enzyme replacement therapy by replacing Hex-A.
1. Hex-A is too big to pass through the blood-
brain barrier.
2. Neurons are unable to take up Hex-A because it is too
big.
 Prevention
•Prenatal diagnosis
•Genetic testing by amniocentesis
•Embryo screening: Test embryo prior to in
vitro fertilization
Select embryos without Tay-Sachs
 Postnatal Gene Therapy
• Purpose: Correction of the deleterious effects of genetic
disease via long term integration of gene sequences into a
patient’s genome
• This property makes the use of retroviral vectors
particularly attractive when considering effective gene
delivery to correct inherited monogenetic disorders
 Types of Postnatal Gene Therapy
• Gene replacement: non-functional or defective gene is
replaced by a new, functional copy of the gene
– Can be accomplished by homologous recombination, although
efficiency is low
• Gene addition: introduction of a gene that is able to produce
a protein not normally expressed in the cell
– i.e. Introduction of a so-called “suicide gene” into cancer cells