Who Should Be Tested?
Screening tests are offered to all pregnant women to assess their risk of having a baby with a birth defect or genetic disorder. If a screening test shows an increased risk of having an affected baby, further tests may be used to diagnose the problem. A birth defect can occur even if the test result does not show a problem. Most tests focus on a certain problem, and not all disorders can be found by testing.

These risk factors may include:

• Family or personal history of birth defects
• Previous child with a birth defect or genetic condition
• Use of certain medicines around the time of conception
• Diabetes before getting pregnant

First Trimester Screening
First trimester screening tests include blood tests and an ultrasound exam. This screening can be done as a single combined test or as part of a step-by-step process. Some women may not need further testing. First trimester screening is done between 11 and 14 weeks of pregnancy to detect the risk of Down syndrome and trisomy 18. The blood tests measure the level of two substances in the mother's blood:

1. Pregnancy-associated plasma protein-A (PAPP-A)
2. Human chorionic gonadotropin (hCG)

Second Trimester Screening
In the second trimester, a test called "multiple marker screening" is offered to screen for Down syndrome, trisomy 18, and neural tube defects. This test measures the level of three or four of the following substances in your blood:

• Alpha-fetoprotein (AFP)
• Human chorionic gonadotropin
• Inhibin-A

First and Second Trimester Screening
The results from both first and second trimester tests can be used together to increase their ability to detect Down syndrome. When both the first- and second-trimester tests are used, about 90-95% of the Down syndrome cases can be detected.

The Next Steps
If the results of a screening test or other factors raise concerns about your pregnancy, diagnostic tests can be done to provide more information. These tests include:

• Detailed ultrasound exam
• Amniocentesis
• Chorionic villus sampling (CVS)

Genes, which are carried on chromosomes, are the basic physical and functional units of heredity. Genes are specific sequences of bases that encode instructions on how to make proteins. Although genes get a lot of attention, it's the proteins that perform most life functions and even make up the majority of cellular structures. When genes are altered so that the encoded proteins are unable to carry out their normal functions, genetic disorders can result.

Gene therapy is a technique for correcting defective genes responsible for disease development. Researchers may use one of several approaches for correcting faulty genes:

• A normal gene may be inserted into a nonspecific location within the genome to replace a nonfunctional gene. This approach is most common.

• An abnormal gene could be swapped for a normal gene through homologous recombination.

• The abnormal gene could be repaired through selective reverse mutation, which returns the gene to its normal function.

• The regulation (the degree to which a gene is turned on or off) of a particular gene could be altered.

In most gene therapy studies, a "normal" gene is inserted into the genome to replace an "abnormal," disease-causing gene. A carrier molecule called a vector must be used to deliver the therapeutic gene to the patient's target cells. Currently, the most common vector is a virus that has been genetically altered to carry normal human DNA. Viruses have evolved a way of encapsulating and delivering their genes to human cells in a pathogenic manner. Scientists have tried to take advantage of this capability and manipulate the virus genome to remove disease-causing genes and insert therapeutic genes.

Target cells such as the patient's liver or lung cells are infected with the viral vector. The vector then unloads its genetic material containing the therapeutic human gene into the target cell. The generation of a functional protein product from the therapeutic gene restores the target cell to a normal state. Some of the different types of viruses used as gene therapy vectors:

• Retroviruses - A class of viruses that can create double-stranded DNA copies of their RNA genomes. These copies of its genome can be integrated into the chromosomes of host cells. Human immunodeficiency virus (HIV) is a retrovirus.

• Adenoviruses - A class of viruses with double-stranded DNA genomes that cause respiratory, intestinal, and eye infections in humans. The virus that causes the common cold is an adenovirus.

• Adeno-associated viruses - A class of small, single-stranded DNA viruses that can insert their genetic material at a specific site on chromosome 19.

• Herpes simplex viruses - A class of double-stranded DNA viruses that infect a particular cell type, neurons. Herpes simplex virus type 1 is a common human pathogen that causes cold sores.

Another nonviral approach involves the creation of an artificial lipid sphere with an aqueous core. This liposome, which carries the therapeutic DNA, is capable of passing the DNA through the target cell's membrane.

Therapeutic DNA also can get inside target cells by chemically linking the DNA to a molecule that will bind to special cell receptors. Once bound to these receptors, the therapeutic DNA constructs are engulfed by the cell membrane and passed into the interior of the target cell. This delivery system tends to be less effective than other options.

Researchers also are experimenting with introducing a 47th (artificial human) chromosome into target cells. This chromosome would exist autonomously alongside the standard 46 — not affecting their workings or causing any mutations. It would be a large vector capable of carrying substantial amounts of genetic code, and scientists anticipate that, because of its construction and autonomy, the body's immune systems would not attack it. A problem with this potential method is the difficulty in delivering such a large molecule to the nucleus of a target cell.

What is the Current Status of Gene Therapy Research?

The Food and Drug Administration (FDA) has not yet approved any human gene therapy product for sale. Current gene therapy is experimental and has not proven very successful in clinical trials. Little progress has been made since the first gene therapy clinical trial began in 1990. In 1999, gene therapy suffered a major setback with the death of 18-year-old Jesse Gelsinger. Jesse was participating in a gene therapy trial for ornithine transcarboxylase deficiency (OTCD). He died from multiple organ failures four days after starting the treatment. His death is believed to have been triggered by a severe immune response to the adenovirus carrier.

Another major blow came in January 2003, when the FDA placed a temporary halt on all gene therapy trials using retroviral vectors in blood stem cells. FDA took this action after it learned that a second child treated in a French gene therapy trial had developed a leukemia-like condition. Both this child and another who had developed a similar condition in August 2002 had been successfully treated by gene therapy for X-linked severe combined immunodeficiency disease (X-SCID), also known as "bubble baby syndrome."

The FDA's Biological Response Modifiers Advisory Committee (BRMAC) met at the end of February 2003 to discuss possible measures that could allow a number of retroviral gene therapy trials for treatment of life-threatening diseases to proceed with appropriate safeguards. FDA has yet to make a decision based on the discussions and advice of the BRMAC meeting.

What Factors Have Kept Gene Therapy From Becoming an Effective Treatment for Genetic Disease?

• Short-lived nature of gene therapy - Before gene therapy can become a permanent cure for any condition, the therapeutic DNA introduced into target cells must remain functional and the cells containing the therapeutic DNA must be long-lived and stable. Problems with integrating therapeutic DNA into the genome and the rapidly dividing nature of many cells prevent gene therapy from achieving any long-term benefits. Patients will have to undergo multiple rounds of gene therapy.

• Immune response - Anytime a foreign object is introduced into human tissues, the immune system is designed to attack the invader. The risk of stimulating the immune system in a way that reduces gene therapy effectiveness is always a potential risk. Furthermore, the immune system's enhanced response to invaders it has seen before makes it difficult for gene therapy to be repeated in patients.

• Problems with viral vectors - Viruses, while the carrier of choice in most gene therapy studies, present a variety of potential problems to the patient — toxicity, immune and inflammatory responses, and gene control and targeting issues. In addition, there is always the fear that the viral vector, once inside the patient, may recover its ability to cause disease.

• Multi-gene disorders - Conditions or disorders that arise from mutations in a single gene are the best candidates for gene therapy. Unfortunately, some the most commonly occurring disorders, such as heart disease, high blood pressure, Alzheimer's disease, arthritis and diabetes, are caused by the combined effects of variations in many genes. Multi-gene or multi-factorial disorders such as these would be especially difficult to treat effectively using gene therapy. For more information on different types of genetic disease, see the article on Genetic Disease Information.

• University of California, Los Angeles, research team gets genes into the brain using liposomes coated in a polymer call polyethylene glycol (PEG). The transfer of genes into the brain is a significant achievement because viral vectors are too big to get across the "blood-brain barrier." This method has potential for treating Parkinson's disease. See "Undercover genes slip into the brain" at NewScientist.com (March 20, 2003).

• RNA interference or gene silencing may be a new way to treat Huntington's. Short pieces of double-stranded RNA (short, interfering RNAs or siRNAs) are used by cells to degrade RNA of a particular sequence. If a siRNA is designed to match the RNA copied from a faulty gene, then the abnormal protein product of that gene will not be produced. See "Gene therapy may switch off Huntington's" at NewScientist.com (March 13, 2003).

• New gene therapy approach repairs errors in messenger RNA derived from defective genes. Technique has potential to treat the blood disorder thalassaemia, cystic fibrosis, and some cancers. See "Subtle gene therapy tackles blood disorder" at NewScientist.com (October 11, 2002).

• Gene therapy for treating children with X-SCID (sever combined immunodeficiency) or the "bubble boy" disease is stopped in France when the treatment causes leukemia in one of the patients. See "'Miracle' gene therapy trial halted" at NewScientist.com (October 3, 2002).

• Researchers at Case Western Reserve University and Copernicus Therapeutics are able to create tiny liposomes 25 nanometers across that can carry therapeutic DNA through pores in the nuclear membrane. See "DNA nanoballs boost gene therapy" at NewScientist.com (May 12, 2002).

• Sickle cell is successfully treated in mice. See "Murine Gene Therapy Corrects Symptoms of Sickle Cell Disease" from the March 18, 2002, issue of The Scientist.

Some Questions to Consider

• What is normal and what is a disability or disorder, and who decides?

• Are disabilities diseases? Do they need to be cured or prevented?

• Does searching for a cure demean the lives of individuals presently affected by disabilities?

• Is somatic gene therapy (which is done in the adult cells of persons known to have the disease) more or less ethical than germline gene therapy (which is done in egg and sperm cells and prevents the trait from being passed on to further generations)? In cases of somatic gene therapy, the procedure may have to be repeated in future generations.

• Preliminary attempts at gene therapy are exorbitantly expensive. Who will have access to these therapies? Who will pay for their use?

Sources: Department Of Energy, Office of Biological and Environmental Research, Human Genome Program