1. 9/22/20151 MRT and Human Research Ethics

2. 9/22/20152 MRT Trials Genetic modification of the early embryo or gametes used to create embryo Primary intent is to alter genes in later-born child, but affects descendants, too Complex subject monitoring

3. Vulnerable Populations Phase I research Impact on fetuses and children Uncertain direct benefit 9/22/20153

4. MRT Trials Embryo Control and Disposition Lack of Regulatory Guidance on Certain MRT Research Issues 9/22/20154

5. Risks to human subjects must be minimized Any unavoidable risks justified by potential benefits to subjects, if any, and by value of knowledge study expected to produce 9/22/20155 Potential Harms and Benefits

6. 9/22/20156 Risk Minimization & Justification What preclinical data needed? Would alternatives diminish justification for MRT research? What is appropriate study population? What monitoring needed?

7. Choice of Study Population Relative risk evaluation [e.g., phase I cancer trials] Uncertainty in determining which cases are at highest risk of serious mitochondrial disorders When there is reasonable chance child would be healthy or mildly affected, harder to justify research risks 9/22/20157

8. 8 Multi-Generational Effects Follow modified children throughout lives Monitor offspring – what tests, etc.? What is sufficient study length?

9. 9/22/20159 Series of Participants Prospective parents Modified children Modified adults Offspring

10. 9/22/201510 Enrollment & Retention Questions Would sufficient number of people enroll and remain in studies to produce data needed to determine safety and efficacy?