True, it is not unusual or irregular for egg retrieval to yield a few less eggs than the number of follicles would suggest. However, when less than 50% of follicles >15mm fail to yield eggs, something is wrong. So how and why does it happen?
First, a little background information…With the LH surge that precedes spontaneous ovulation and also with the hCG trigger shot given to induce ovulation following the use of fertility drugs, the egg undergoes “ripening” to prepare for fertilization. This involves (among other events) a rapid halving in the number of its chromosomes (meiosis). At the same time, enzymes are released that loosen the cells (cumulus oophorus) that surround and bind the egg to the inner wall of the follicle. This is necessary to enable the egg to come free at ovulation and/or at the time of egg retrieval.
The problem is that with poorly developed eggs, the latter mechanism often fails, leaving such eggs tightly “stuck” to the follicle wall and unable to come free, often in spite of vigorous attempts to flush them loose. That is why the more difficult it is to successfully aspirate an egg at egg retrieval, the more likely it is that such an egg is chromosomally abnormal and “incompetent” (i.e. incapable of developing into a normal pregnancy). This state of affairs is most commonly encountered in women with diminished ovarian reserve (i.e. “poor responders”), women over 40 and in women with polycystic ovarian syndrome (PCOS) who do not receive an optimal protocol of controlled ovarian hyperstimulation (COH).
So the term “Empty Follicle Syndrome” is a misnomer! Yet the circumstances surrounding failure of numerous follicles to yield the eggs they contain at the time of egg retrieval only serves to underscore the need to individualize COH protocols and to time the administration of the “hCG trigger”, precisely.
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6 comments:
Hello Dr Sher
I am 41 y/o. My two first long luppron protocol produced respectively 3 and 7 embryos (40 y/o at the time), the latter one with a pregnancy that ended at 7 weeks. A third long luppron protocol ended with a cancelled cycle which looked like oversuppression (with one ovaries that shut down and the other were only 2/3 follicles that developed). On my fourth attempts on a GnRH antagonists protocol, it seems that I ovulated 2 or 3 hours before the retrievals (while the last US indicated something like 8 /9 follicles)over 15 mm day 12 of the cycle. It seems my best cycle in term of stimulation but ended with no eggs retrieved. What can have happened ? how could this be avoided ? should I change protocol ?
It sounds as if you experienced a "premature LH surge", a condition where high LH levels cause “follicular exhaustion” resulting in poor egg quality and often failure of the egg to come free with aspiration . But the term “premature LH surge” is a misnomer since it suggests a sudden unanticipated rise in LH that occurs as a “terminal event” or an isolated occurrence. In actuality, what happens is the result of a progressive escalation in LH (the so called “staircase effect”) that through a persistent rise in stromal androgens, ultimately exhausts the follicle and damages the egg irreparably.
A more accurate term might be “premature luteinization.”
Geoff Sher
hai dr
my sister undergone for ivf 2 times . both time , the dr said there was no egg in follicles .is empty follicle syndrome and the above condition are same ?
what are the remedies other than doner / surrogacy .
also i am trying for 3 years , is it genetically happen or only coz of hormones
I just finished a donor cycle. Can you tell me if missing 1 of the gonnul and 2 of the menopur injections could cause empty follicles? I confused my calendar and started both medicines a day and days (respectively) late. I didn't mention it to the doctor as I thought I still had time to make up the injections. However, seeing many follicles he called for retrieval 2 days later and so I was told to discontinue the medications and take the trigger shot. I didn't realize that not all follicles would produce eggs. We only retreived 3 eggs and I feel terrible, like I really messed this up. Please advise.
I suspect that the protocol of stimulation could have played a role in egg "competence" and that in turn might have prevented the eggs from detaching from the inner wall of the follicles after the hCG trigger. As this article indicates, tThere is really no such thing as an empty follicle.
One of the commonest reasons for "empty follicle syndrome" is, in my opinion, a less than ideal protocol for ovarian stimulation.
Geoff Sher
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