Prospects for Prenatal Gene Therapy


Somatic prenatal gene therapy (PGT) aims at treatment/prevention of progressive tissue/organ damage in early‐manifesting life‐threatening and otherwise incurable genetic diseases. Preclinical investigations applying different vectors and transgenes on several animal models including nonhuman primates have shown PGT to provide better access to target cells and their progenitors, induce tolerance to vector/transgenic protein and reduce the required amount of vector in comparison to postnatal gene therapy. Human application of PGT is now technically possible, however, safety issues regarding potential adverse effects on fetal development, oncogenesis‐induction and germline transmission as well as ethical considerations concerning risk–benefit assessment and alternative reproductive choices have so far prohibited human trials. Increasing the safety profile, for example, by use of novel vector systems and long‐time primate safety/efficiency studies, may prospectively validate PGT for selected human applications. High standards regarding information given to prospective patients (informed consent) and to the public on the aims, benefits and remaining risks will play an important role in any future clinical application of PGT.

Key Concepts:

  • Somatic gene therapy addresses genetic diseases of the treated individual at the level of the molecular defect.

  • Prenatal gene therapy of early onset genetic disease prevents irreparable damage to tissues and organs and induces postnatal tolerance to therapeutic transgenic proteins.

  • Prenatal gene delivery can reach proliferating precursor cell compartments more effectively than postnatal gene therapy.

  • Different animal models including models of human genetic disease are required to establish optimal vectors and routes for gene delivery including those applicable in humans, to demonstrate the therapeutic efficiency of the delivered gene therapy, and to monitor and investigate the occurrence of potential adverse effects.

  • In utero gene therapy could provide an alternative to termination of pregnancy or acceptance of an affected child after prenatal diagnosis of a genetically affected fetus, or to in vitro fertilisation followed by embryo selection in families with preconceptional knowledge of a specific genetic risk.

  • Current options to avoid birth of a genetically affected child (termination of pregnancy, preimplantation diagnosis/embryo selection) impose very high demands on the outcome of human prenatal gene therapy with respect to its level of safety and effectiveness.

  • Ethical considerations regarding the assessment and communication of the risks and benefits of prenatal gene therapy and its perception by affected families, the medical profession and the general public will play an important part in decisions on the clinical application of this novel therapeutic approach.

Keywords: prenatal (fetal, in utero) gene therapy; prenatal diagnosis of; genetic disease; fetal development; gene therapy vectors; animal models; oncogenesis; germline gene transfer; targeted gene correction (genome editing); immune tolerance; ethical considerations

Figure 1.

Topical in utero gene transfer in mouse. Topical application can be performed under ultrasound guidance or by visualisation of the fetal body parts through the uterine wall. Left: Intra‐amniotic delivery results in gene transfer to the skin, the airways and gut epithelia due to spontanious ‘breathing’ and swollowing movements of the fetus. Right: Examples of local application to the intercostal musculature, the thoracic and peritoneal cavities and to the limb musculature. Blue staining indicates gene transfer from vector expressing β‐galactosidase using enzyme reaction for detection. (a) Skin: Unpublished; (b) Airways Macro: Reproduced with permission from Buckley et al. (2005) Gene Therapy 12 (3) Fig. 1H. © Nature Publishing Group; (c) Airways histology: Unpublished; (d) Gut: Reproduced with permission from Douar et al. (1997) Gene Therapy (1997) 4, page 888 Fig. 6a (gut). © Nature Publishing Group. (e) Mouse fetus: Unpublished; (f–h) Muscle: Reproduced with permission from Gregrory et al. (2004) Gene Therapy 11, p. 1119 © Nature Publishing Group.

Figure 2.

Intravenous in utero gene transfer in mouse. Left: Schematic drawing and photograph of mouse fetus within the uterine horn. The embryonic yolk sac vessels can be seen and accessed through the uterine wall (needle puncture) as shown in the photograph. The yolk sac vessels deliver a large proportion of the blood flow directly to the liver, similar to the umbilical vein, which is used for gene delivery in larger mammals (centre). The blood flow reaches the heart through the inferior vena cava and is shunted through the foramen ovale and the ductus arteriosus into the aorta, essentially bypassing the lung circulation. Therefore, this systemic delivery route mediates gene transfer predominantly to the liver and, depending on the vector used, also to the heart, brain, visceral organs and peripheral musculature. Blue staining indicates gene transfer from the vector expressing β‐galactosidase using enzyme reaction for detection. Braun staining using immunohistochemical reaction for the detection of β‐galactosidase expression. (a) Schematic embryo: Reproduced with permission from Waddington et al. (2005) Molecular Therapy 11 (5) Fig. 1. © Nature Publishing Group. (b) Fetus in utero: Unpublished; (c) Fetal circulation: Reproduced with permission from Moore Keith. Embyologie Lehrbuch und Atlas, Schattauer 3rd German ed Fig. 14–40, p. 374. Elsevier licence © Elsevier. (d) Brain: Unpublished; (e,f) Heart, Liver in situ and histology: Reproduced with permission from Waddington (2003) Blood 101 (4) Fig. 1A and B. © American Society of Haematology.

Figure 3.

Late gestation (102 and 140th day) in utero gene transfer by umbilical vein injection in fetal sheep 1×1011 pfu adenovirus (AdRSVβgal) was injected at late gestation (0.96) into the intrahepatic umbilical vein of fetal sheep. (a) Ultrasound picture of needle insertion into umbilical vein at the time of injection. Umbilical vein injection (US): Reproduced with permission from Themis et al. (1999) Gene Therapy 6, 1239–1248 (Fig. 1). © Nature Publishing Group. (b) Braun immunohistological staining of β‐galactosidase in hepatocyte nuclei indicates successful gene transfer. Liver histology: Unpublished.

Figure 4.

First proof of principle for long‐term postnatal expression of potentially therapeutic levels of human antihaemophilic factor IX in a nonhuman primate model (Macaca fascicularis) after in utero gene therapy. 1.5×1010 vector genomes (AAV2/8 LP1‐hIX) were injected at late gestation (0.96) into the intrahepatic umbilical vein of this newborn rhesus monkey (a). hFIX‐expression was followed by consecutive blood sampling from birth. Note the stabilisation of the hFIX concentration after a first rapid drop after birth in spite of continuous expansion of blood volume (weight increase). In this animal, the hFIX level stabilises at 5.6 μg/ml, which corresponds to 112% of the normal human FIX level. In other animals from this experiment stable levels between 7% and 22% were reached. (a) New‐born Rhesus monkey: Unpublished. (b) Fix blood concentration: Reproduced with permission from Mattar et al. (). © Nature Publishing Group.



ACOG CON (2009) Preconception and prenatal carrier screening for genetic diseases in individuals of Eastern European Jewish descent. Obstetrics & Gynecology 114: 950–953.

Allison M (2013) Genomic testing reaches into the womb. Nature Biotechnology 31: 595–601.

Blaese RM (1993) Devlopment of gene therapy for immunedeficiency: adenosine deaminase deficency. Pediatric Research 33(suppl. 1): S49–S53.

Boye SE, Boye SL, Lewin AS and Hauswirth WW (2013) A comprehensive review of retinal gene therapy. Molecular Therapy 21(3): 509–519.

Buckley SMK, Rahim AA, Chan JKY et al. (2011) Recent advances in fetal gene therapy. Therapeutic Delivery 2(4): 461–469.

Cavazzana‐Calvo M and Fischer A (2007) Gene therapy for severe combined immunodeficiency: are we there yet? Journal of Clinical Investigation 117: 1456–1465.

Cavazzana‐Calvo M, Hacein‐Bey S, de Saint Basile G et al. (2000) Gene therapy of human severe combined immunodeficiency (SCID)‐X1 disease. Science 288: 669–672.

Cecchini S, Virag T and Kotin RM (2011) Reproducible high yields of recombinant adeno‐associated virus produced using invertebrate cells in 0.02‐ to 200‐liter cultures. Human Gene Therapy 22: 1021–1030.

Condiotti R, Goldenberg D, Giladi H et al. (2014) Transduction of fetal mice with a feline lentiviral vector induces liver tumors which exhibit an E2F activation signature. Molecular Therapy 22(1): 59–68.

Coutelle C, Douar A‐M, College WH and Froster U (1995) The challenge of fetal gene therapy. Nature Medicine 1: 864–866.

Coutelle C and Waddington SN (eds) (2012) Methods in Molecular Biology, Concepts, Methods and Protocolls, Springer Protocols, vol. 891, pp. 1–392. New York, Dortrecht, Heidelberg, London: Humana Press, Springer.

David AL, McIntosh J, Peebles DM et al. (2011) Recombinant adeno-associated virus mediated in utero gene transfer gives therapeutic transgene expression in the sheep. Human Gene Therapy 22: 419–426.

Deprest J, Toelen J, Debyser Z et al. (2011) The fetal patient – ethical aspects of fetal therapy. Facts, Views and Vision In Obgyn 3: 221–227.

Endo M, Henriques‐Coelho T, Zoltick PW et al. (2010) The developmental stage determines the distribution and duration of gene expression after early intra‐amniotic gene transfer using lentiviral vectors. Gene Therapy 17: 61–71.

Friedmann T (1992) A brief history of gene therapy: Nature Genetics 2: 93–98.

Gaj T, Gersbach CA and Barbas CF (2013) ZFN, TALEN, and CRISPR/Cas‐based methods for genome engineering. Trends in Biotechnology 31: 397–405.

Galetto R, Duchateau P and Paques F (2009) Targeted approaches for gene therapy and the emergence of engineered meganucleases. Expert Opinion on Biological Therapy 9: 1289–1303.

Gelbaya TA (2010) Short and long‐term risks to women who conceive through in vitro fertilization. Human Fertility (Camridge) 13: 19–27.

Gillman J (1948) The development of the gonads in man, with a consideration of the role of fetal endocrines and histogenesis of ovarian tumours. Contributions to Embryology 32: 81–92.

Gonzaga S, Henriques‐Coelho T, Davey M et al. (2008) Cystic adenomatoid malformations are induced by localized FGF10 overexpression in fetal rat lung. American Journal of Respiratory Cell and Molecular Biology 39: 346–355.

Hacein‐Bey‐Abina S, Von Kalle C, Schmidt M et al. (2003) LMO2‐associated clonal T cell proliferation in two patients after gene therapy for SCID‐X1. Science 302: 415–419.

Hagedorn C, Wong SP, Harbottle R and Lipps HJ (2011) Scaffold/Matrix attached region‐based nonviral episomal vectors. Human Gene Therapy 22: 915–923.

Hanna J, Wernig M, Markoulaki S et al. (2007) Treatment of sickle cell anemia mouse model with iPS cells generated from autologous skin. Science 318: 1920–1923.

Hyde S (2013) Gene therapy for cystic fibrosis from basic research to clinical impact. Available at:

Jakob M, Muhle C, Park J et al. (2005) No evidence for germ‐line transmission following prenatal and early postnatal AAV‐mediated gene delivery. Journal of Gene Medicine 7: 630–637.

Kazazian H (1999) An estimated frequency of endogenous insertional mutations in humans. Nature Genetics 22: 130.

Lee CC, Jimenez DF, Kohn DB and Tarantal AF (2005) Fetal gene transfer using lentiviral vectors and the potential for germ cell transduction in rhesus monkeys (Macaca mulatta). Human Gene Therapy 16: 417–425.

Li C, Narkbunnam N, Samulski RJ et al. The Joint Outcome Study Investigators (2011a) Neutralizing antibodies against adeno‐associated virus examined prospectively in pediatric patients with haemophilia. Gene Therapy 19: 288–294.

Li H, Haurigot V, Doyon Y et al. (2011b) In vivo genome editing restores haemostasis in a mouse model of haemophilia. Nature 475: 217–221.

Li Z, Dullmann J, Schiedlmeier B et al. (2002) Murine leukemia induced by retroviral gene marking. Science 296: 497.

Maier DA, Brennan AL, Jiang S et al. (2013) Efficient clinical scale gene modification via zinc finger nuclease‐targeted disruption of the HIV co‐receptor CCR5. Human Gene Therapy 24: 245–258.

Mason CA, Bigras JL, O'Blenes SB et al. (1999) Gene transfer in utero biologically engineers a patent ductus arteriosus in lambs by arresting fibronectin‐dependent neointimal formation. Nature Medicine 5: 176–182.

Mattar CN, Nathwani AC, Waddington SN et al. (2011) Stable human FIX expression after 0.9G intrauterine gene transfer of self‐complementary adeno‐associated viral vector 5 and 8 in macaques. Molecular Therapy 19: 1950–1960.

Mattar CN, Waddington SN, Biswas A et al. (2013) Systemic delivery of scAAV9 in fetal macaques facilitates neuronal transduction of the central and peripheral nervous systems. Gene Therapy 20: 69–83.

Mehta V, Abi‐Nader KN, Peebles DM et al. (2012) Long‐term increase in uterine blood flow is achieved by local overexpression of VEGF‐A(165) in the uterine arteries of pregnant sheep. Gene Therapy 19: 925–935.

Nathwani A, Tuddenham EG, Rangarajan S et al. (2011) Adenovirus‐associated virus vector‐mediated gene transfer in hemophilia B. New England Journal of Medicine 365: 2357–2365.

Nowrouzi A, Cheung WT, Li T et al. (2013) The fetal mouse is a sensitive genotoxicity model that exposes lentiviral‐associated mutagenesis resulting in liver oncogenesis. Molecular Therapy 21: 324–337.

Park PJ, Colletti E, Ozturk F et al. (2009) Factors determining the risk of inadvertent retroviral transduction of male germ cells after in utero gene transfer in sheep. Human Gene Therapy 20: 201–215.

Porada C, Tran N, Eglitis M et al. (1998) In utero gene therapy: transfer and long‐term expression of the bacterial neo(r) gene in sheep after direct injection of retroviral vectors into preimmune fetuses. Human Gene Therapy 9: 1571–1585.

Rahman SH, Maeder ML, Joung JK and Cathomen T (2011) Zinc‐finger nucleases for somatic gene therapy: the next frontier. Human Gene Therapy 22: 925–933.

Saada J, Oudrhiri N, Bonnard A et al. (2010) Combining keratinocyte growth factor transfection into the airways and tracheal occlusion in a fetal sheep model of congenital diaphragmatic hernia. Journal of Gene Medicine 12: 413–422.

Schambach A, Zychlinski D, Ehrnstroem B and Baum C (2013) Biosafety features of lentiviral vectors. Human Gene Therapy 24: 132–142.

Shaw SW, David AL, Blundel M et al. (2011) Sheep amniotic fluid derived CD34+ stem cells engraft in NOD‐SCID gamma mice and in lambs after prenatal autologous transplantation. European Society of Gene and Cell Therapy Conference 2011 published in Human Gene Therapy 22: A2–A22.

Snyder MW, Simmons LVE, Kitzman JO et al. (2013) Noninvasive fetal genome sequencing: a primer. Prenatal Diagnosis 33: 547–554.

Stehle IM, Scinteie MF, Baiker A et al. (2003) Exploiting a minimal system to study the epigenetic control of DNA replication: the interplay between transcription and replication. Chromosome Research 11: 413–421.

Tarantal AF, Chen H, Shi TT et al. (2010) Overexpression of TGF‐{beta}1 in foetal monkey lung results in Prenatal Pulmonary Fibrosis. European Respiratory Journal 36: 907–914.

Themis M, Schneider H, Kiserud T et al. (1999) Successful expression of beta-galactosidase and factor IX transgenes in fetal and neonatal sheep after ultrasound-guided percutaneous adenovirus vector administration into the umbilical vein. Gene Therapy 6: 1239–1248.

Themis M, Waddington SN, Schmidt M et al. (2005) Oncogenesis following delivery of a non‐primate lentiviral gene therapy vector to fetal mice. Molecular Therapy 12: 763–771.

Waddington S, Buckley S, Nivsarka M et al. (2003) In utero gene transfer of human factor IX to fetal mice can induce tolerance of the exogenous clotting factor. Blood 101: 1359–1366.

Waddington S, Nivsarkar M, Mistry A et al. (2004) Permanent phenotypic correction of Haemophilia B in immunocompetent mice by prenatal gene therapy. Blood 104: 2714–2721.

Wong SP, Argyros O, Coutelle C and Harbottle RP (2011) Non‐viral S/MAR vectors replicate episomally in vivo when provided with a selective advantage. Gene Therapy 18: 82–87.

Wu C, Endo M, Yang BH et al. (2013) Intra‐amniotic transient transduction of the periderm with a viral vector encoding TGFbeta3 prevents cleft palate in Tgfbeta3(−/−) mouse embryos. Molecular Therapy 21: 8–17.

Ye X, Gao GP, Pabin C et al. (1998) Evaluating the potential of germ line transmission after intravenous administration of recombinant adenovirus in the C3H mouse. Human Gene Therapy 9: 2135–2142.

Further Reading

Friedmann T and Roblin R (1972) Gene therapy for human genetic disease? Proposals for genetic manipulations in humans raise difficult scientific and ethical problems. Science 175: 949–955.

RAC (2000) Prenatal gene transfer: scientific medical and ethical issues. A report of the Recombinant DNA Advisory Committee. Human Gene Therapy 11: 1211–1229.

Urnov FD, Miller JC, Lee YL et al. (2005) Highly efficient endogenous human gene correction using designed zinc‐finger nucleases. Nature 435: 646–651.

Zanjani ED and Anderson WF (1999) Prospects for in utero human gene therapy. Science 285: 2084–2088.

Contact Editor close
Submit a note to the editor about this article by filling in the form below.

* Required Field

How to Cite close
Coutelle, Charles(Feb 2014) Prospects for Prenatal Gene Therapy. In: eLS. John Wiley & Sons Ltd, Chichester. [doi: 10.1002/9780470015902.a0025275]