About the Empty Follicle Syndrome

A large number of IVF specialists don’t really know exactly how to deal with the Empty Follicle Syndrome. This is a guide for IVF doctors dealing with EFS.

In any IVF clinic, vaginal egg collection is a very routine procedure and all it takes is 20 minutes to do it. Good doctors will typically get 1 egg from every mature follicle. However, a complication called the empty follicle syndrome can have a negative impact on vaginal egg collection.

Empty follicles- What are these?

In the egg collection process, the doctor has to puncture the follicles- at times, the embryologist is unable to get any eggs at all, in the follicles. In the OR, the procedure seems like a pretty straightforward one. When the follicles are aspirated, they and the follicular fluid flows freely into the test tubes. However, when the embryologist scans this fluid under the microscope, he doesn’t see any eggs at all.

Not a common occurrence

This occurrence is uncommon as well as unexpected; at this point, most doctors haven’t a clue as to what they should be doing, as they haven’t had to deal with this condition in the past. This is a medical emergency that tends to largely get managed very badly. Most doctors just blindly continue with the procedure; and once it’s done they leave the OR. Later when the embryologist reports that he hasn’t been able to get any eggs at all, they are completely fazed.

Patients are completely taken aback too, when they are told that no eggs have been found. In most instances, at this point, the doctor recommends they the couple use donor eggs and in some cases, manages to coerce the patients into taking this option. In reality, this is a sign of poor medical management and doctors have to know how these crises should be managed.

The reasons

The thing to keep in view is that 99% of the time, this syndrome occurs because the patient hasn’t taken her hCG injections the way she should. This could be because of:

  • The patient may have forgotten to dissolve the powder in the solvent while taking the trigger shot, and taken only the inert solvent
  • She may have taken an HMG injection instead of the hCG
  • She may have mis-timed it
  • Might have spilled the drug, and was too scared to tell the doctor what happened

The way we manage empty follicle syndrome at our clinic

  • Firstly, we use a double lumen needle for the egg collection, and flush each and every follicle at least 4 times, with the expectation of finding one egg in each follicle
  • If the embryologist doesn’t get any eggs after we have flushed 3 mature follicles , we stop the procedure
  • We do a detailed analysis, in order to ensure that the patient has taken the trigger injection at the right time
  • In making the diagnosis of empty follicle syndrome we use a rapid home pregnancy test kit in order to check the urine (obtained by catherisation) for the presence of hCG (Instead of urine, it's also possible to do the test on the aspirated follicular fluid)
  • If the patient has taken her hCG properly, we would expect to find a positive pregnancy test. This rules out the diagnosis of empty follicle syndrome, and we can then continue with the egg collection
  • However, if the pregnancy test is negative, the diagnosis of empty follicle syndrome is confirmed
  • At this point we stop the procedure, leaving the rest of the follicles intact, and wheel the patient out of the OR
  • We give the patient an additional HMG injection to support follicular growth; and do a blood test to measure estrogen and hCG levels. (Remember that we will get the results of the blood tests only after a few hours)
  • We then give the patient another hCG injection , and reschedule the egg collection 36 hours after this second hCG shot
  • If we are worried about the quality of the hCG injection, we may use recombinant hCG ( such as Ovitrelle) to trigger ovulation ; and we may also increase the dose of hCG to 20000 IU ( instead of the standard 10000 IU we use routinely)
  • The next day, we review the blood test results. We would expect the estradiol levels to be high; and the hCG level to be less than 100 mIU/ml, thus confirming the diagnosis of EFS
  • An ultrasound scan at this time confirms that the follicles are still intact.

A better chance

When we are doing the 2nd egg retrieval (this is planned 36 hours post the 2nd hCG shot , we expect to see intact follicles & also expect to retrieve eggs from each of these follicles. We repeat the blood hCG level again, to document the diagnosis & expect this to be more than 100 mIU/ml. With the use of this protocol, we are able to salvage the situation and this gives the patient a much better chance at getting pregnant.

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Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.