The human embryo CRISPR paper with Shoukhrat Mitalipov as senior author is coming soon.
It will reportedlybe focused on the use of CRISPR to genetically modify viable human embryos for reversal of a disease-associated mutation. While strangely press already broke early on this paper last week, as much as a week before the paper comes out, and that press suggests very positive data, how clear will that be from the paper itself?
Here are some ideas on the big 5 questions (some include nested questions) likely to come up from this now eagerly-anticipated paper:
1. How much residual off-target activity was there and if it was very low, how was that achieved? How low does it have to be where someday this hypothetically could be used for actual reproduction with a strong expectation of safety and efficacy? Was WGS done on many embryos to look comprehensively for unpredicted off-target activity?
2. At the sasaran site, were indels ever created instead of the desired precise edits?
3. Is the goal of Mitalipov and the larger team on this paper to actually use this approach in the germline for heritable human gene editing within say 5 years? If so, how will it be limited to just that and not other applications such as infertility or trait modification? What kind of ethics review went into this paper and how does it compare to the NAS report on human gene editing?
4. Will others use this paper as a foundation to argue for a more permissive policy on human germline edits?
5. And/or conversely will there be a political reaction here in the US (and maybe elsewhere) leading to restrictions on human CRISPR research or other areas of innovative research in the US?
Note: this post was written prior to my seeing the human embryo CRISPR paper.
The FDA sent a stern letter today to Dr. John Zhang, PhD, MD, the physician who last year created a genetically modified human embryo in the U.S. and then exported it to Mexico where he self-reported creating a genetically modified baby boy.
While the genetically modified baby created in Mexico was reportedly seemingly OK, it’s not clear what kind of health issues he might face in the future and I haven’t seen much data on him. I believe his parents subsequently declined to have him participate in future research so that will be an issue in terms of knowing outcomes.
I’ve blogged before about Zhang and his cross-border effort and I’ve hosted a guest post with a Mexican perspective on that as well. According to the new FDA untitled letter (why not a warning letter considering the letter seems full of what seem like “warnings”?), Zhang made the genetically modified embryo in the U.S. without approval (which the FDA can’t legally give but in theory would be required) from the agency plus he exported it to Mexico also without the required approval.
To be clear, what Zhang did has nothing to do with CRISPR or directly with the big news this week on Shoukhrat Mitalipov having CRISPR’d human embryos. I don’t believe that the FDA would have any oversight over what Mitalipov did research-wise with CRISPR’ing human embryos in his Nature paper and it wasn’t federally funded. However, Mitalipov did create genetically modified human embryos as well, but via CRISPR. Also, Mitalipov is reportedly interested in genetic and reproductive technologies to potentially prevent mitochondrial disease in humans, but his Nature paper wasn’t on that and again Zhang didn’t use CRISPR.
Instead what Zhang did is a technique that has been variously called 3-person IVF, 3-parent baby technology (not a name I like), mitochondrial replacement therapy, nuclear DNA transfer, etc. It is technically called, ““spindle transfer for assisted pregnancy in patients with mitochondrial disease.”
The goal with this 3-person IVF technology is to combine the germinal material of two parents-to-be with the enucleated egg of a donor to avoid diseased mitochondria carried in the egg of the mother-to-be. This is all done with the hope of avoiding the transfer of mitochondrial disease to an offspring.
A very similar 3-person IVF approach is technically permitted now in the UK with proper licensure and approval, but not in the U.S. It’s unclear what rules are currently in place in Mexico on this. It’s a very good overall goal to work toward preventing horrible mitochondrial diseases, but I see 3-person IVF as a super risky procedure in its various forms and it could easily do more harm than good.
The FDA letter to Zhang includes a mention of marketing of the human genetic modification approach via his company Darwin Life, Inc. In addition, the FDA says of Zhang’s procedure:
“Moreover, as noted above, FDA cannot accept an IND for a clinical investigation involving your HCT/P, and such human subject research cannot legally be performed in the United States. Nor is exportation permitted unless it meets the requirements of an applicable export exemption.”
Strong words. The FDA also says, “We request that you notify this office, in writing, of the steps you have taken or will take to address the violation noted above and to prevent recurrence.”
I asked Bioethicist Leigh Turner of the University of Minnesota for his take on the letter:
“The FDA letter identifies several key issues. It mentions specific marketing claims while indicating that such claims can only be made after obtaining a valid biologics license. It notes that substantial evidence must be provided to obtain a BLA, and the way to generate such evidence is by having an Investigational New Drug application in effect. It also states that the company had no such IND in effect and had agreed not to use its spindle technology transfer agenda in the U.S. until an IND is in effect. But of course there is a catch: the FDA cannot and will not consider such an IND application. This bind appears to have prompted an end run around federal regulations by exporting genetically modified embryos to Mexico. (The letter doesn’t mention how many embryos have been shipped from the U.S. to Mexico.) Challenging this apparent effort to engage in regulatory arbitrage, the FDA letter states that Zhang and his companies do not have permission to export genetically modified embryos and the embryos do not fall within regulatory exemptions. Translation: Zhang cannot circumnavigate federal regulations by shipping genetically modified embryos to a clinic in Mexico. In short, several noncompliant practices are identified, with the usual reminder that such FDA letters are not all-inclusive and the burden is on the company to comply in all respects with federal regulations. Bottom line: Zhang needs to stop making marketing claims about offering a “cure” for mitochondrial disease and he cannot ship genetically modified embryos out of the U.S. to jurisdictions with less stringent regulations.”
What happens next?
Does the agency actually take some kind of practical action on this? Does Zhang proceed but just make the genetically modified human embryos in Mexico or somewhere else outside the U.S.? What happens with the marketing and the company Darwin Life?
Big HT to Leigh Turner for finding the FDA letter.
The FDA issued a historic statement today promising to more clearly define its regulatory policies on stem cell therapies and to take strong action on some stem cell clinics that it views as “bad actors”. I’ve never the FDA use such clear-cut language before. I give big kudos to new FDA Commissioner Scott Gottlieb.
It already took some action too on clinics in Florida and in California. So today we heard about both a bold statement of vision on how the FDA will deal with stem cell clinics and also it took real action. For instance, the FDA issued a warning letterto Kristin Comella of US Stem Cell Clinic (a subsidiary of US Stem Cell Inc) in Florida, an organization linked to negative outcomes in patients including blindness. It also apparently raided a stem cell business in San Diego, StemImmune Inc.
This taken together is a very big deal. For me as someone who has been following and trying to make a difference about the stem cell clinic duduk kasus for more than 7 years, I find today very encouraging. Better late than never?
The FDA also indicated today and has suggested before in a blog postby Gottlieb, that it may soften some regulations of stem cell treatments. We’ll have to wait and see how that plays out and what impact it has.
Overall, what does this all mean and what happens next? This story is still breaking so there’s a lot to think about, but on my first run through of it I’ve got 6 major thoughts and questions on today’s development.
How much further will the FDA go with actual enforcement actions? What we heard about today is a major positive step, but it’s just one step out of many needed along the path toward reining in the out of control stem cell clinic industry. With around 600 stem cell clinics in the U.S., FDA action on just 2 is positive but not enough. More to come?
Will the FDA define fat stem cells as a drug (or not) in upcoming guidances? If yes, how will it handle the fact that there are hundreds of clinics using fat stem cells without proper licensing and approval of the product/treatment as a drug? If not and fat stem cells are viewed as not necessarily drug products, will the FDA then narrow the scope of permitted applications of fat stem cells used not as a drug to only include homologous use? I.e., “fat stem cells are drugs if used on non-fat-related health problems”? May there be exceptions to that limitation?
How will the FDA handle non-homologous use of bone marrow cells in the commercial sector? This kind of use is pretty common out there too by clinics. To be clear, some clinics use bone marrow cells in a homologous fashion and without more than minimal manipulation, but I’m not referring here to those.
Amniotics? Will the FDA work to deal with the growing duduk kasus of unapproved, amniotic stem cell offerings? If so, what steps will it take?
What about networks of stem cell businesses? How will the new FDA under Gottlieb view networks of stem cell businesses such as Cell Surgical Network? This comes to mind because the FDA in its PR mentioned key member of that network as where StemImmune’s unapproved product was administered to patients: “California Stem Cell Treatment Centers in Rancho Mirage and Beverly Hills, California. ” The founders of Cell Surgical Network are listed on its own website as part of the StemImmune Inc. leadership team.
Will other entities like state medical boards use this FDA action as a spring-board to get off the sidelines and take positive action too? After all, some of the providers at stem cell clinics I’ve talked to over the years often recite a similar mantra that it isn’t the FDA that regulates them, but rather state medical boards. So, state medical boards and other governmental bodies, are you watching and willing to do something? So far state medical boards have mainly stood on the sidelines on the stem cell clinic problem, but that may be changing.
Shoukhrat Mitalipov points to an image of a potential CRISPR’d embryo inside an incubator at the Center for Embryonic Cell and Gene Therapy in Portland, Ore. Photo credit: Rob Stein on NPR.org, re-used with permission.
The debate over whether the main conclusions of the Nature paper on human embryo CRISPR led by Shoukhrat Mitalipov’s lab at Oregon Health Sciences University (OHSU) are correct remains unresolved. Note that Nature just added an editorial alert just above the references section to their paper:
“Updated online 02 October 2017. Editorial Note: Readers are alerted that some of the conclusions of this paper are subject to critiques that are being considered by editors. Some of these critiques have been publicly deposited in preprint form. A further editorial response will follow the resolution of these issues.”
This research should be shaking us up on another level besides just the core science. Recent developments deepen societal and ethical questions about this kind of research. A unique look by NPR inside Mitalipov’s lab ups the stakes and I believe should give us pause. The surprisingly huge scale and clear clinical intent together magnify the risks.
Also, if Mitalipov’s team in particular actually might not be CRISPR’ing the human embryos the way they thought they were, could many of the human embryos being made and used in their work not be contributing to useful data production? The importance of this question is magnified by the large-scale of the embryo use. In responding to the concerns raised by the Egli preprint that questioned the central conclusions of the Ma Nature paper, Mitalipov mentioned that his lab has worked with “hundreds of human embryos”.
Hundreds?
Were those all CRISPR’d?
How many hundreds are we talking about and where did all the human eggs come from to make those? Overall, how many human embryos are being made and/or used for genetic research around the world? It’s hard to say but CRISPR genetic modification of human embryos is likely now ongoing widely across the globe, with active work in at least four and probably more countries. Could there soon be in the range of thousands of human embryos having been CRISPR’d and if so, does that number matter?
Kathy Niakan’s group in the UK just published a knockout of the OCT4 gene in healthy human embryos that involved dozens of embryos, but only those leftover from IVF procedures, and another team, this time from China led by Zhou Songyang and Junjiu Huang, reported in a new paper that they actually cloned somatic cells to make human embryos via somatic cell nuclear transfer (SCNT), which they then modified using a somewhat different version of gene editing called “base editor” involving chemical modification of DNA.
Researchers in Sweden have explicit governmental approval permitting them to do CRISPR on healthy human embryos. Since they’ve had this green light for quite some time they probably are well into such work already and we can expect a paper from them soon. There also have been several older published papers on CRISPR genetic modification of human embryos (here, here, and here).
Taken all together this means that genetic modification of human embryos is rapidly becoming more common and that musim is likely to continue. Large-scale human embryo genetic modification isn’t going to be clearly ethically permissible in all cases. Some of the upbeat perspectives on this kind of research could be too aspirational with premature clinical objectives.
CRISPR ‘Magic’. Rob Stein was the NPR reporter invited into the Mitalipov lab. He was taken to the specific place in the lab for CRISPR of human embryos that Mitalipov reportedly referred to this way:
“This is our small room, but that’s where usually lots of big science happened,” says Mitalipov, who was born in the former Soviet Union. “We believe this room is really magic in terms of science.”
Magic? That’s a risky word for us scientists to use.
This small room is where they inject CRISPR into human embryos. The human embryos are often apparently made there earlier by IVF, including using donor eggs collected in the same building a few floors down or elsewhere.
Assembly line feel. Mitalipov and members of his team showed Stein the process by which they put CRISPR-Cas9 into the human embryos. One of the most striking aspects of Stein’s report was that the OHSU lab can attempt to CRISPR many human embryos over a short period of time. Stein reported after seeing a first CRISPR’ing of a human embryo that:
“Mitalipov and his team immediately do a second edit and then transfer the embryos to a larger incubator. The scientists will then spend the next few days monitoring live video of the two embryos, along with 17 others they had edited the weekend before, to see how they develop.”
Nineteen human embryos made and CRISPR’d in a day or two?
Even if this doesn’t happen every day, just this one lab alone could produce and genetically modify hundreds of human embryos in a short period of time. Is that scale of human embryo production and CRISPR for research ethically permissible? Who knows? It seems the justification is based in this case on hoped-for future clinical benefit. Mitalipov has indicated that he definitely wants to try this in the clinic in a heritable manner.
In addition, health risks to egg donors are often downplayed despite there being astonishingly little data on whether egg donation is safe, and anecdotal reports of cancer in young donors (see recent NYT article). The use of CRISPR in human zygotes should be understood to be transformative, both in potentially positive and negative ways. It is not just another experiment. It requires extraordinary care and sober reflection as well as transparency.
Even more transparency and openness about perspectives would be useful. It’d be great if Mitalipov penned a perspectives kind of piece to place his research here in a larger context, discussing things like preimplantation genetic diagnosis (PGD; a.k.a. “embryo screening for mutations”) and why he believes germline CRISPR is even needed (more on PGD below). I haven’t really seen him get into the meaty issues in interviews so far. For example, it’s still not clear to me why he thinks germline CRISPR would be better than PGD alone.
In the gray zone. In the last few years discussion of CRISPR human germline research has taken off. That’s great. For instance, there have been many meetings with wide-ranging discussions. These have yielded beneficial results in the form of greater awareness and exchange of diverse ideas, but we are a long way from having some clear framework for what’s permissible and what isn’t when it comes to changing the genetic code of human embryos and potentially humans. Such a framework may vary by country as well. Collectively as a field we are in a gray zone. The National Academies report released earlier this year did a nice job of outlining many challenges issues with human gene editing, but in my view it ended up not being too much in the gray zone too. They left the door open to human germline CRISPR.
Some are wanting to go through and quickly. “I don’t think I’m playing God,” Mitalipov says as quoted by NPR, “We have intelligence to understand diseases, eliminate suffering. And that’s what I think is the right thing to do.”
Don’t forget PGD. It is concerning just how often the already proven alternative of embryo screening by PGD is not brought up when people discuss heritable human genetic modification as a basis to try to prevent genetic diseases. Basically, in almost every clinical case one can imagine, there would be no point to CRISPR’ing human embryos because you can just simply screen for mutant versus non-mutant embryos without taking the big risks of genetically modifying them. In fact, you’ve got to do PGD when you do CRISPR anyway to know what is going on so why not just do PGD alone instead?
PGD isn’t perfect but from an unbiased viewpoint CRISPR has to have some very strong case for its superiority over PGD for the arguments for its eventual clinical use to make sense. If such cases cannot be made and PGD almost always is going to better, should we be CRISPR’ing massive numbers of human embryos based on the supposed justification of a reasonable expectation of safe and effective, future clinical use?
Advancing knowledge or wanting to go to the clinic? It’s important to point out that the research that Niakan and others is described as being done to advance knowledge, not to enable future germline use of CRISPR in humans, and again they used leftover IVF embryos rather than making new embryos by doing IVF themselves or cloning. Even if the Niakan team did not report a definite blockbuster scientific finding on targeting OCT4 in human embryos, I still think their work was interesting and I generally am supportive of that kind of research if done with a good scientific justification, strong transparency, proper institutional/governmental approvals, and bioethical discussions in advance. However, if many more such experiments go on to largely recapitulate what is already known from mouse studies without major unique human-specific findings then the case for use of healthy human embryos may become more difficult. See my ABCD plan for human genetic modification.
I asked Marcy Darnovsky, Executive Director of the Center for Genetics and Society about the Stein NPR article and the importance of including PGD in the dialogue about human embryo CRISPR, and here’s what she said:
“There’s no way to accurately think through the enormous safety and societal risks of human germline editing without knowing just how weak its medical justification is. You don’t need to engineer your future child’s genes to avoid passing on serious genetic conditions. The embryo screening technique PGD can accomplish that in pretty close to every situation. Embryo selection itself raises questions about what counts as serious disease and what’s just human variation. But the fact is, PGD is safe, effective, and has been available in fertility clinics for decades.”
Bottom line. As CRISPR work on human embryos is expanding around the world, societal and bioethical issues take on more urgency. Maybe we can’t or shouldn’t entirely hit “pause” on this kind of research even if it is just limited to the lab without clinical intent, but it feels like some folks have hit “fast forward” instead and there might be an almost race-like atmosphere, which boosts risks on many levels.
Broader discussion, transparency, and thoughtful contemplation are urgently needed.
For a long time at the end of each year, I’ve been making stem cell predictions for the coming year. Most often I’ve been making a “top 20” list of predictions and today’s post has my list for 2019.
You can see how I did for 2018 here, which might have been my best year ever for predictions. We’ll see if I can match that here for 2019. I doubt it. However, I do think my prediction that 2019 will be the worst year ever for snake oil stem cell clinics will be spot on.
I make these prognostications based not on a stem cell crystal ball (although I like to joke about that) but rather via a combination of information found both inside and outside the public domain. It generally ends up substantially better than a coin toss in terms of outcomes.
Here’s the list of predictions for 2019. As usual it’s a mix of expected upbeat and bad news. Some predictions are combinations of related predictions.
Organoids. The upper size limit of organoids such as brain organoids will continue to grow as vascularization and other related work moves forward. This advance will enable more cool research, but keep raising tough ethical questions too related to this so-called human “mini brains”. The recent report of fetal human brain wave-like activity in organoids is relevant here.
Parkinson’s Disease. More concrete reasons for hope on clinical stem cell clinical for Parkinson’s Disease. The news of the 1st patient transplanted in Japan via an IPS cell-based product in 2018 is encouraging. Not a prediction exactly, but I’m hoping to see more IPS cell good news, possibly on PD, in the US too.
Two biotechs on the move. Some major twist for the stem cell biotech ViaCyte including not just science-wise, but also or instead potentially talk of an IPO or an acquisition. Most likely this is good news. I hope! A second biotech, Athersys, has some much-needed good news. Further, unfortunately, on the whole the stem cell biotech arena doesn’t do great in 2019.
Trump-Pence. The Trump administration (including most likely VP Pence) at least talks about restrictions on embryonic stem cell research. I hope this doesn’t get ugly.
CIRM. A formal announcement of either a 2020 state proposition for more funding for the California Stem Cell Agency, CIRM, or a major private philanthropy plan.
CRISPR babies A. Two opposing developments. Supposed claims of independent confirmation that the CRISPR baby guy He Jiankui did make mutations in human babies (e.g. an independent lab such as George Church’s analyzes the sequencing data), but probably also news that He didn’t actually make the mutations he said in the twins. Confusing, right? Unclear if anyone including the Chinese government will have access to independently (and ethically) sample the twins and parents for their own analysis of the data for real confirmation.
CRISPR babies B.The Chinese government will announce some kind of punitive action against He Jiankui. Could it end up being too harsh or just largely symbolic?
The FTC will take some further action on one or more stem cell firms in the US.
The FDA will issue at least 3 warning letters to stem cell businesses in 2019. It’ll do more on other stem cell fronts too I’m guessing.
State Medical Boards. One or more state medical boards will make news on action on stem cell clinics (I’m hoping including here in my state of California). The recent newsof a California Medical Board task force makes this more likely.
State Attorney Generals. At least one state Attorney General office will take legal action on stem cell clinics. It could even be two. There may also be local law enforcement action on stem cell clinics.
State law. At least one more state will have a bill emerge related to stem cell clinics, possibly Florida again.
Two big federal court cases. The FDA will win the initial rulings in its lawsuits against U.S. Stem Cell (USRM) and Cell Surgical Network/California Stem Cell Treatment Center. It’s possible that both the cases won’t be entirely resolved by year’s end though, pending appeals.
U.S. Stem Cell metamorphosis. Despite the appeals in the suits mentioned above in prediction 15, USRM will undergo a dramatic change most likely involving either no longer being a U.S. publicly traded stock/FEC action, moving a sizable chunk of its focus overseas (maybe mostly in the Middle East), or shifting away from fat products. I’m not formally predicting this, but it’s also possible that in the next 12-24 months USRM may no longer exist.
Cell Surgical Network 2019 predictions. This clinic chain will exhibit shrinkage of its affiliates or other related negative news. They could also move a chunk of their work overseas.
Stemgenex. The proposed class action suit against Stemgenex either gets its class status or continues to heat up.
Bad actor chiropractors. At least one and probably more chiropractors find themselves on the hot seat because of their stem cell business, potentially facing criminal action or temporary loss of their licenses.
Birth-related “stem cell” products & clinics take a hit. The unproven birth-related (amniotic, placental, umbilical, Wharton’s jelly) unproven clinic and supplier arena, intimately tied to chiropractor firms, finds itself in more hot water. I don’t think it’s a good year for supplier Liveyon.
Multiple sclerosis (MS). Ending on a more positive note, more encouraging news on the legit front of stem cells for multiple sclerosis (MS) most likely via HSCT combined with some kind of immunoablation. Many of us are eagerly awaiting a new paper on this front in 2019.
In this post I list some recent interesting stem cell and science pubs including artificial human embryo research.
Artificial human embryos. Screenshot of Fig 4d Nat Cell Bio 2019 Simunovic et al. From the caption, “Molecular signature of EMT: downregulation of the adherent junction protein E-CAD and the expression of N-CAD in the BRA+ region. Images are representative of three imaged 3D colonies stained with the BRA, E-CAD and N-CAD combination.”
Engineered human embryo research continues.
Scientists for years have been advancing the types of embryo-like structures made from both human and other creature’s cells. In a new Nature Cell Bio pub entitled, “A 3D model of a human epiblast reveals BMP4-driven symmetry breaking”, a team led by Eric Siggia pushed this further. See an image from the paper I’ve included that shows signs of the primitive streak and epithelial to mesenchymal transition (EMT) in the embryo-like structures.
They report being able to model a human epiblast of a sort from human embryonic stem cells. From the abstract, “Here, we use human embryonic stem cells to generate an in vitro three-dimensional model of a human epiblast whose size, cell polarity and gene expression are similar to a day 10 human epiblast. A defined dose of BMP4 spontaneously breaks axial symmetry, and induces markers of the primitive streak and epithelial-to-mesenchymal transition. We show that WNT signalling and its inhibitor DKK1 play key roles in this process downstream of BMP4.”
You can read a couple past posts I did on pubs about artificial embryos here and here.
You can imagine that engineered human embryo research raises ethical issues too. In an NPR piece by Rob Stein, he has this quote on that level:
“It’s very exciting work,” says Insoo Hyun, a bioethicist at the Case Western Reserve University and Harvard Medical School who was not involved in the research. “But it does send folks down the road to thinking very seriously about where the limits may be ethically for this work.”
What do you think of engineering human embryo-like structures?
Here are some other interesting recent pubs and news.
The FDA issued a 
For a long time at the end of each year, I’ve been making stem cell predictions for the coming year. Most often I’ve been making a “top 20” list of predictions and today’s post has my list for 2019.