IVF- guide to effectiveness

In July 1978 Louise Brown was hailed as the world’s first “test-tube baby”, born through the fertility treatment IVF.

In July 1978 Louise Brown was hailed as the world's first "test-tube baby", born through the fertility treatment IVFBut how has IVF effectiveness improved compared with modern IVF procedures?

Louise’s birth was cloaked in secrecy. Even her father John’s first visit to see her in Oldham General Hospital was under the eye of police officers, who lined the corridor outside.

She was the first to be born through in-vitro fertilisation (IVF), a process in which an egg is removed from the woman’s ovaries and fertilised with sperm in a laboratory, before being implanted into the uterus.

It is a treatment used to enable couples with a range of fertility problems to conceive a child, and now allows same sex couples and single mothers to have children too.

Technological advancements mean – according to 2013 estimates – more than five million people worldwide have been born through IVF.

But in 1978 it was highly experimental, and Dr Mike Macnamee, chief executive at the world’s first IVF clinic – Bourn Hall in Cambridge – believes Louise “really was a miracle”.

The two men who pioneered the treatment – gynaecologist Patrick Steptoe and Nobel Prize-winning physiologist Robert Edwards – “had gone through hundreds of embryo transfers before Louise was conceived”, he adds.

The pair had joined forces a full 10 years earlier, with skills that perfectly complemented one another – Edwards having developed a way to fertilise human eggs within the laboratory and Steptoe having devised a method for obtaining the eggs from the ovaries.

When Louise’s mother Lesley was put in contact with Steptoe by her doctor, she was warned there was a “one in a million” chance of success.

So when it worked, it was such a momentous scientific advancement that the birth had to be filmed – under agreement with the government – to give documented evidence that Louise was indeed her mother’s.

This is a far cry from modern procedures, which – owing much to the work of Bourn Hall in the 1980s – follow a refined and well established clinical process.

“Once Steptoe and Edwards worked out how to fertilise the egg, they very soon wanted to restrict the number of embryos they transferred into women – so they didn’t have too many multiple births,” Dr Macnamee explains.

“Development of the freezing technique in the mid-80s meant they could implant one or two embryos into the would-be mother and then freeze other embryos for future use, saving her the uncomfortable procedure of having the eggs removed again.”

Progress can also be seen in the modern use of ultrasound imaging to harvest the eggs under a mild sedation, rather than the form of keyhole surgery known as laparoscopy that was previously employed.

Techniques developed in the late 1980s also made a big difference in treating male infertility by injecting single sperm directly into the egg.

These, and other, small incremental steps mean the success rate for each round of IVF has grown from 10% to 40% since the early 80s, when Dr Macnamee’s first role included the hands-on task of mixing the eggs and sperm in a petri dish.

The chances of successfully conceiving through IVF decline with age, but the process is now more effective per cycle than natural reproduction. It does not, however, have approval from all quarters.

Dr Macnamee thinks the chances of women conceiving through IVF will only increase in future – and says he hopes to see a 60% success rate in IVF cycles before he retires.

One prominent area of research is aimed at exploring the way in which embryos interact with the lining of the womb when they are implanted.

Many believe it is when the two fail to engage with each other that the IVF cycle can prove unsuccessful.

Progress is slow – as there is no model to undertake tests in the lab – but Dr Macnamee believes this line of research could be key. “If we understand that better, it’d be the next big breakthrough,” he says.

Three IVF cycles a minimum treatment requirement

A charity is calling for couples who need help conceiving to have access to three cycles of IVF instead of two.

Three IVF cycles a minimum treatment requirementIn 2013 a working group, set up by the Scottish government, recommended eligible couples should be offered up to three treatments. But that would only be after health boards had reduced IVF waiting times.

Infertility Network UK said it was a “no-brainer” there should now be three cycles as waiting times have fallen.

New IVF criteria was introduced in July 2013, following recommendations by the National Infertility Working Group.

The changes were designed to standardise fertility treatment across Scotland to prevent a “postcode lottery”.

Giving evidence to Holyrood’s health committee, the charity’s chief executive Susan Seenan said: “The group recommended three cycles and said that once the waiting times were down to below 12 months, at the latest early 2015, they would consider moving to three cycles.

“It just doesn’t seem to be happening as fast as we would like it to. We just think now that the waiting times are down, that it is a no-brainer – we should move to offering everybody who is eligible three cycles.”

IVF treatment guidelines

  • A guaranteed two full cycles of IVF, as well as unlimited frozen transfers for eligible couples until the woman’s 40th birthday
  • Women aged between 40 and 42 will be offered one full cycle of IVF provided they meet all necessary criteria
  • From 31 March, 2015, all eligible couples will start treatment within 12 months of being accepted for IVF treatment
  • Obese women – those with a Body Mass Index (BMI) over 30 – will have to lose weight and have a BMI of 29.9 or less before treatment
  • If either partner smokes, they will need to have stopped before treatment is started

Susan Seenan added: “Everybody in the group was agreed that…three cycles was the best possible way to move forward for patients.

“Why anybody would not want to move forward with that, I have no idea, unless it is finance related.”

Fertility treatment is currently available to those under 40, and is not offered to women who are obese.

In addition, couples need to have been in a stable relationship for two years and neither partner can smoke for three months before treatment begins.

Both partners also need to be methadone-free for a year before IVF starts.

Women aged between 40 and 42 are eligible for one cycle of fertility treatment if they have never previously undergone the procedure.

IVF success rates may be boosted by time lapse embryo imaging

Time lapse imaging- which takes thousands of pictures of developing embryos can boost the success rate of IVF, according to British research.IVF success rates may be boosted by time lapse embryo imagingThe article Retrospective analysis of outcomes after IVF using an aneuploidy risk model derived from time-lapse imaging without PGS was reported in Reproductive BioMedicine Online, can be used to select embryos at low risk of defects.

Scientists at the CARE fertility group say such informed selection can improve birth rates by 56%.

Other experts say the result is exciting, but the study of 69 couples is too small to be definitive.

The research followed the couples at the CARE fertility clinic in Manchester last year, when 88 embryos were imaged and implanted.

The process involves putting the embryos into an incubator and imaged them every 10 to 20 minutes.

Continual embryo monitoring through time-lapse imaging is aimed at selecting those with the lowest risk of aneuploidy – where the cells have chromosome abnormalities. Aneuploidy is the single biggest cause of IVF failure.

But this form of embryo screening is a predictive rather than diagnostic tool.

Couples at high risk of passing on a chromosomal abnormality may prefer to have Pre-implantation Genetic Screening. This invasive test removes cells from the early embryo for analysis. It costs around £2,500 on top of the £3,000 charged for conventional IVF.

The researchers classified the embryos as low, medium or high risk of chromosome abnormalities based on their development at certain key points.

Eleven babies were born from the low risk group (61% success rate) compared to five from the medium risk group (19% success rate) and none from those deemed high risk.

“In the 35 years I have been in this field this is probably the most exciting and significant development that can be of value to all patients seeking IVF,” said Prof Simon Fishel, managing director of CARE Fertility Group.

“This technology can tell us which embryo is the most viable and has the highest potential to deliver a live birth – it will have huge potential. This is almost like having the embryo in the womb with a camera on them.”

In standard IVF, embryos are removed from the incubator once a day to be checked under the microscope. This means they briefly leave their temperature-controlled environment and single daily snapshots of their development are possible.

Obese women restricted in NHS IVF treatments

New NHS IVF treatment rules have been drawn up in Scotland.
Obese women restricted in NHS IVF treatmentsCouples who need help conceiving will be guaranteed two free infertility treatments from 1 July, however the treatments will only be available to those under 40, and it will not be offered to women who are obese.

In addition, couples need to have been in a stable relationship for two years and neither partner can smoke for three months before treatment begins.

Both partners also need to be methadone-free for a year before IVF starts

If either partner smokes they will need to have stopped before treatment is commenced

Women aged between 40 and 42 will be eligible for one cycle of fertility treatment if they have never previously undergone the procedure.

The new IVF criteria has been approved by the Scottish government.

The guarantees came as the National Infertility Group published a report with recommendations on new criteria.

The eligibility criteria for free fertility treatment in Scotland currently includes a female age limit of 39; the patient must not already have a child living at home; and they must have had less than three previous funded embryo transfers.

Scotland’s Public Health Minister Michael Matheson said the government was committed to “providing fair, reliable and faster access to IVF treatment”.

He insisted that it was important to end the different approaches across the country and to offer “equity”.

“We are investing £12 million over three years to help drive down waiting times for IVF treatments, and waiting times are already reducing in a number of NHS board areas.

“We also have to be responsible about the effects of smoking and obesity on pregnancy and beyond. Smoking not only reduces the effectiveness of IVF, but also doubles the risk of pregnancy loss.

“NHS boards will offer patients the support needed to make the lifestyle changes demanded of the new criteria.

“The safety of mother and baby is of utmost importance and the recommendations will ensure healthier outcomes for both families and babies born as a result of IVF treatment.”

Men need to become match fit if they want to be fathers

Men have been warned they need to become ‘match fit’ if they want to be fathers, as a fertility study claims too much attention has been focused on mothers’ weight.Men need to become match fit if they want to be fathersWhile the health risks surrounding obesity and pregnancy have largely been centred on overweight mothers, the focus is now on men to lose weight.

Less efficient sperm results in smaller foetuses, poor pregnancy success and reduced placental development.

The discovery was made by reproductive experts from the University of Melbourne, Australia.

World Health Organisation figures show that a staggering 48 per cent of adult males are overweight or obese – making the findings even more of a worry.

The research was conducted by Professor David Gardner, Dr Natalie Hannan and PhD student Natalie Binder.

Prof Gardner, Head of the Department of Zoology, said: “A lot of men don’t understand they need to be healthy before conceiving. Sperm needs to be ‘match fit’ for the games of life and creating life is the biggest thing that we can do.”

The study used IVF to determine the effects of paternal obesity on embryo implantation into the womb and foetal development.

PhD candidate Natalie Binder generated embryos from both normal weight and obese male mice.

She said: “We found development was delayed in the foetuses produced from obese fathers.  Furthermore, placental weight and development was significantly less for embryos derived from the sperm of obese males.

These findings indicate that paternal obesity not only negatively affects embryo development, but also impacts on the successful implantation into the womb.

“This then results in a small placenta which impairs fetal growth and development with long term consequences for the health of the offspring. Our study provides more information about the impact of obesity in men and their ability to start a family and the need to shed kilos in preparation to conceive.”

The findings were presented at the Annual Scientific Meeting of the Endocrine Society of Australia and the Society for Reproductive Biology 2012.

From: http://multi-vitamins.eu/men-need-to-become-match-fit-if-they-want-to-be-fathers

NHS rationing is putting health at risk says doctors’ leader

Dr Mark Porter, the new head of the BMA, says NHS cuts are ‘morally wrong’ and present a serious risk to patients. NHS rationing is putting health at risk says doctors' leaderThe NHS is putting patients’ health at risk by denying them drugs and operations because of growing rationing being imposed to save money, the new leader of Britain’s doctors has warned.

The drive to meet demanding efficiency targets is so serious that the NHS is offering some GPs surgeries extra money if they send fewer patients for tests and treatment in hospital — a move condemned as “morally wrong” by Dr Mark Porter, the British Medical Association’s recently elected chair of council.

In his first interview since taking up the post Porter said the NHS was offering fewer and fewer services to patients and that many had been “cut out”, often against doctors’ wishes.

The shrinking of the NHS’s “offer” to the public was being hastened by the coalition’s health reforms, creeping privatisation of services and the system’s need to save £20 billion by 2015, Porter claimed.

Those pressures mean the fear that a patient may be harmed because they are denied a test or treatment “is a realistic concern”, said Porter. The same changes, especially the growing number of  private firms providing NHS services, also threaten to fragment the health service by making it less of an integrated system and have a severe impact on recent improvements in the quality of care, he added.

The NHS has come under growing criticism for making it harder for patients to have operations for routine conditions such as hernia, cataracts, grommets, wisdom teeth, or hip or knee replacement, and denying infertile couples IVF.

Rationing of access to certain procedures deemed not worthwhile by the NHS- postcode lottery- which is still piecemeal and localised, will soon become much more widespread as the spending squeeze in the service tightens, said Porter. “You see it happening in examples now, but it’s when it becomes service-wide in a few years’ time, if the current policies continue, that the population will notice in the wider sense.”

NHS organisations’ lists of treatments they will no longer pay for mean that “bits of the NHS are being parcelled off and taken out of the NHS offer year by year”. Although the NHS constitution guarantees universal and comprehensive healthcare “there’s lots of areas where bits of the NHS have been taken out of the offer”, Porter said. “It’s no longer a comprehensive service. We can see the effect of people to whom we have to say: I’m sorry, this treatment is no longer available.”

The use of referral management centres, in which family doctors’ decisions to refer a patient to hospital are analysed by a third party before any treatment can be given, “are particularly distressing for GPs who know how they would like to deal with patients but find their ability to do so is more constrained than ever before”. The situation was in stark contrast to “rhetoric” from ministers about how patients and GPs are being given more power than ever before as a result of their changes to the NHS in England, Porter added.

Both existing NHS primary care trusts (PCTs) and the clinical commissioning groups (CCGs) led by local GPs that will replace them next April are offering GP practices money in return for sending fewer patients to hospital to receive what can be expensive care there, despite NHS leaders and ministers having told them to restrict access only on clinical, and not financial, grounds.

Porter said that while the BMA supported schemes to improve the quality of referrals, such offers potentially gave GPs a conflict between their clinical judgment and personal self-interest, as GPs who run a practice can decide either to spend income on improving services or use it to boost their salaries. “It’s morally wrong and professionally wrong. Paying a direct financial incentive like that can be a direct financial incentive to the person themselves and that incentive shouldn’t be there. Doctors’ minds should be on what’s best for the patient, not on whether the PCT will sub them for certain types of financial behaviour,” he said.

From:  http://www.guardian.co.uk/nhs-rationing-risking-lives-doctors-leader

Women can delay menopause indefinitely with ovary transplants

Women can remain fertile indefinitely after successful ovarian transplants lead to births and delay the menopause doctors have told a conference.Women can delay menopause indefinitely with ovary transplantsA technique to remove pieces of ovary, store it for decades and then replace it with delicate surgery could effectively put a woman’s menopause ‘on ice’, doctors said.

The only thing preventing them from having babies into their old age would be their physical ability to carry a pregnancy, they said.

The controversial notion would allow career women peace of mind with a fertility insurance policy so they can find a partner, settle down and become financially secure before starting a family.

By delaying the menopause they could also avoid the increased risk of osteoporosis and heart disease that come with the end of their fertile life but may raise the risk of breast and womb cancer.

A conference heard how 28 babies have been born worldwide to patients who either had their own ovarian tissue removed before treatment that would have left them infertile and replaced afterwards or twins where one donated tissue to the other.

Most of the children have been conceived naturally without the need for IVF for drugs.

Dr Sherman Silber, an American surgeon, has been involved in transplants for 11 women at St Luke’s Hospital in St Louis, Missouri, US, said: “A woman born today has a 50 per cent chance of living to 100. That means they are going to be spending half of their lives post-menopause.”

“But you could have grafts removed as a young woman and then have the first replaced as you approach menopausal age. You could then put a slice back every decade.  Some women might want to go through the menopause, but others might not.”

That would mean women would not have to “watch their body clocks”, he said, and would only be physically limited by their ability to carry a baby and give birth.

Transplants carried out eight years ago are still working showing the technique is ‘robust’ and it should no longer be considered experiemental, he said.

One transplant from one 38-year-old to her identical twin, has lasted seven years so far without failing.  In that time the recipient has had two healthy baby boys and a baby girl, all without IVF, conceiving the last aged 45.

Originally it was thought the transplants would only last months, or a few years at most, giving the women just a brief chance of conceiving. But Dr Silber said early hopes had been surpassed.

In Belgium, a woman has given birth after her ovarian tissue was frozen for decade, and in Italy a woman has just had a healthy baby girl after her tissue was frozen for seven years.

He and European colleagues have presented their findings this week at the European Society for Human Reproduction and Embryology (ESHRE) in Istanbul.

They wrote: “All modern women are concerned about what is commonly referred to as their ‘biological clock’ as they worry about the chances of conceiving by the time they have established their career and/or their marriage and their financial stability.

“Most of our cured cancer patients, who have young ovarian tissue frozen, feel almost grateful they had cancer, because otherwise they would share this same fear all modern, liberated women have about their ‘biological clock’.”

The first operation, conducted on Oudara Touirat in Belgium in 2003, led to a pregnancy and successful birth a year later.

Strips of her ovarian tissue were removed before chemotherapy for Hodgkin’s lymphoma and were replaced after she was given the all clear.

The majority of women who have undergone the procedure have had cancer but doctors said it is now time to extend it to others.

Thousands denied IVF because of British red tape restrictions

Thousands of couples in Britain are being denied the chance to become parents because the country has one of the most restrictive policies in Europe when it comes to publicly funding fertility treatment.Thousands denied IVF because of British red tape restrictionsThey were speaking after a study was presented at an IVF conference showing that only Russia and Ireland offer worse access.

At the moment about 13,000 babies are born every year in Britain thanks to IVF and another technique called ICSI, which is mainly used to counter male infertility.

However, the new study indicates that number could be up to three times higher, if our policies matched those of the most generous nations.

Among those with more generous IVF programmes include Slovakia, Montenegro, Czech Republic and Slovenia.

Dr Mark Connolly, an American health economist based at Groningen University in The Netherlands, compared public funding of Fertility treatments and how frequently they was used in 23 European countries in 2008. The UK came third from bottom in terms of reimbursement, and also had among the lowest number of “assisted reproduction technology” cycles per million people.

Europe-wide, he said there was a “highly significant relationship between high levels of public reimbursement and high levels of utilisation”.

For example in Belgium, one of the most generous countries, there were 2,479 cycles per million people. In the UK there were only 825.

Under guidelines issued by the National Institute Curbing Expenditure (Nice), primary care trusts (PCTs) should offer up to three full cycles of IVF – which includes giving hormones that stimulate release of eggs, egg retrieval, test-tube fertilisation, reimplantation of viable embryos and freezing of unused embryos for later use – to infertile women from 23 to 42.

In practice, only a quarter do so, found a group of MPs who looked at provision across England last year. Since then some have tightens restrictions, such as refusing treatment to smokers and the obese, to reduce costs.

Speaking at the annual conference of the European Society for Human Reproduction and Embryology (ESHRE) in Istanbul, Dr Connolly said most English PCTs were “feeble” in their ability to fund three cycles of IVF.

Clare Lewis-Jones, chairman of the National Infertility Awareness Campaign, said: “For thousands of couples here, the dream of having a child of their own remains elusive: many are denied IVF because their PCT or health board is reluctant to fund sufficient treatment.

“We will continue our fight for fair and equitable access to IVF and ICSI on the NHS, a situation that simply does not exist in the UK.  Despite the fact that IVF was pioneered in our country, we are near the bottom of the list in terms of the number of cycles performed.  Those suffering from the disease of infertility have the right to expect the chance to have a healthy baby of their own.”

From: http://www.telegraph.co.uk/Thousands-denied-IVF-because-of-British-restrictions

IVF clinics accused of putting money before safety

IVF clinics in the UK are practising aggressive fertility treatments that are putting women and children at unjustified risk, experts say.IVF clinics accused of putting money before safetyThe commercially driven industry uses unnecessary procedures, high doses of pwerful drugs and risky interventions to help desperate couples spending thousands of pounds to conceive.

But a milder, safer approach to IVF could provide equivalent success rates over a longer period at a lower cost and could enable the NHS to double the number of patients treated for the same budget. The UK is lagging behind other countries in adopting the approach, the experts say.

Professor Geeta Nargund, head of reproductive medicine at St George’s Hospital, south London, told a conference in Copenhagen that there was increasing evidence that the standard method of IVF used in the UK, involving stimulating the ovaries with high doses of drugs to produce large numbers of eggs for harvesting, was detrimental to the health of women and caused chromosomal abnormalities in the resulting embryos.

“High-dose stimulation can have distressing side effects on the woman, the most serious of which is called ovarian hyper-stimulation syndrome (OHSS). This condition in its severe form is potentially fatal and women have died,” Professor Nargund told the conference. She added: “A recent confidential inquiry into maternal deaths in the UK showed that OHSS was now one of the biggest causes of maternal mortality in England and Wales.”

There were almost 30,000 cases of OHSS – which can cause chest pains shortness of breath and, in rare cases, kidney failure and death – between 1991 and 2007 in the UK, according to figures obtained from the Human Fertilisation and Embryology Authority (HFEA) in response to a request under the Freedom of Information Act.

“There is no doubt that women subjected to this kind of stimulation are at serious health risk and yet the HFEA appears to hide behind a confidentiality clause when it comes to releasing clinical complications,” Professor Nargund said, speaking at the congress of the International Society for Mild Approaches in Assisted Reproduction, of which she is president.

IVF has grown increasingly popular over the last two decades with 45,000 women treated in the UK in 2010. The use of less toxic drugs to stimulate the ovaries, known as “mild” IVF, produces fewer eggs and a lower pregnancy rate per cycle. But it means recovery is quicker and patients can repeat the treatment within a month. Standard IVF takes months to recover from.

Clinics in Scandinavia, Belgium, Holland, France, Canada, Japan and South Korea have adopted mild IVF, but, in the US and UK, high-dose IVF is preferred.

“The aim should be to do no harm to the mother and the child. If we continue with expensive, aggressive, old-fashioned IVF it will exclude too many from treatment. We could double the number of patients treated at no extra cost and the complications would be less,” Professor Nargund said.

Bill Ledger, former head of the IVF unit at the Royal Hallamshire Hospital, Sheffield, and a former member of the HFEA who is now a professor of obstetrics and gynaecology at the University of New South Wales, Australia, said: “It is time for a change. In the past we were so desperate to help couples have children we used high doses of drugs and put back three embryos. Now we have the luxury of good pregnancy rates it is time to emphasise safety as well as efficacy.”

Professor Ian Cooke, former president of the British Fertility Society and chief executive of the Low Cost IVF Foundation, said: “We are over-stimulating women, driving the cost up and the complications up. The first aim should be to reduce complications.”

Susan Seenan, deputy chief executive of the Infertility Network UK, which represents infertile couples, said: “The first thing women will want to know is what are their chances of a baby with mild IVF? If patients have to undergo multiple cycles it might mean more disappointment and upset.”

A spokesperson for the HFEA said: “There is currently no data which we hold that is an accurate marker of poor clinical practice or is a predictor for the likelihood of a patient experiencing OHSS. The HFEA continues to monitor this research even though it has limited regulatory powers in this area.”

From: http://www.independent.co.uk/ivf-clinics-accused-of-putting-money-before-safety-7743505

New IVF postcode lottery meaningless ruling by NICE quango

Gay couples and women over 40 will be entitled to the same free IVF treatment as heterosexual couples on the NHS for the first time under new guidelines published today.New IVF postcode lottery meaningless ruling by NICE quangoSame sex couples will be given the same rights as heterosexual couples under guidance issued by the killer quango National Institute for Curbing Expenditure (NICE).

The NHS will also extend the upper age limit for IVF by three years to 42, following advice that suggests many women in their late 30s and early 40s could conceive after treatment.

Fertility experts questioned whether health authorities could afford to widen eligibility criteria, when only a quarter currently fund three cycles of IVF for infertile couples, as recommended by Nice.

Gedis Grudzinskas, emeritus professor of obstetrics and gynaecology at Barts and the Royal London Hospital, said that while the new guidance reflects “social changes” there were questions over whether NHS trusts could afford it.

“How do we reconcile the changes in society and equality of access to healthcare, with the economic predicament?” he said.

The new guidelines call on health authorities in England and Wales to fund fertility treatment known as intra-uterine insemination (IUI), using donor sperm, for people in same-sex relationships.

The move follows a relaxation in the law, made under Labour in 2008, to put same sex parenting on an equal legal footing.

The recommendation follows implementation of the Human Fertilisation and Embryology Act 2008. It abolished requirement for fertility clinics to take into account a child’s need for a father or a male role model before agreeing to treatment. Gay couples or single women now need only show they can provide “supportive parenting”.

Demand from gay couples paying privately for fertility services has subsequently boomed, say clinics. Official figures show the number of lesbian couples undergoing IVF rose from 178 in 2007 to 417 in 2010.

One cycle of IVF can cost up to £8,000 privately. Because success rates are low – typically 20 per cent for a 38-year-old – couples can spend tens of thousands on treatment.

Meanwhile Josephine Quintavalle, founder of Comment on Reproductive Ethics, described the same-sex move as “absurd”.

She said: “We are not prepared to accept what constitutes fertility from a biological perspective. Fertility treatment is very important but in this case what we are trying to do is rewrite biology.”

Under the Nice guidelines, women aged 40 to 42 deemed to have no chance of conceiving naturally should be offered one full IVF cycle. In this age group one in eight will give birth after one cycle.

From: http://www.telegraph.co.uk/Gay-couples-and-women-over-40-to-get-free-IVF-treatment-on-NHS