Empty Follicle Syndrome (EFS) - a guide for IVF doctors


Many IVF specialists do not know how to deal with Empty Follicle Syndrome (EFS). This is a guide for IVF doctors dealing with EFS.

Vaginal egg collection is a very routine procedure in an IVF clinic. The procedure is over in about 20 minutes, and good doctors will usually get one egg from each mature follicle.However, one of the dreaded complications which can mar a vaginal egg collection is called the empty follicle syndrome.

What are empty follicles?

The doctor starts puncturing the follicles, and is dismayed when the embryologist does not get any eggs whatsoever in the follicles. The procedure in the OR seems to be technically straightforward. The follicles when aspirated and there is free flow of follicular fluid into the test tubes. However, when the embryologist scans the follicular fluid under his microscope, he does not find any eggs as all !

An uncommon occurrence

This is unexpected and uncommon; and many doctors are completely stumped as to what to do when this happens, because they have not dealt with this condition earlier. This is actually a medical emergency, but is often managed badly.

Because many doctors don't know how to deal with this problem, they tend to just continue with the procedure blindly, and suck out the follicular fluid from all the follicles. After completing the procedure, they then leave the theater. When the embryologist then reports that he cannot find any eggs, they tell the patient - Sorry, we did not get any eggs at all.

Patients are stunned into disbelief and don't know how to respond. The doctor may offer the use of donor eggs at this time - and often patients are bulldozed into agreeing, in order to salvage a bad situation.

Read more-Why wasn't the doctor able to collect any eggs ?

Actually, this is a sign of poor medical management. So how should a doctor manage this crisis ?

Remember that 99% of the time, empty follicle syndrome occurs because the patient has not taken the hCG injection properly . This could occur for multiple reasons:

  • 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

How do we manage empty follicle syndrome in 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
  • However, if the embryologist does not get any eggs after we have flushed three 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 sho
  • 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

At the time of the second egg retrieval , which is planned 36 hours after the second hCG shot , we expect to see intact follicles ; and expect to retrieve eggs from each of these follicles. In order to document the diagnosis , we repeat the blood hCG level again , and expect this to be more than 100 mIU/ml.

Using this protocol , it is possible to salvage the situation, and give the patient a very good chance at getting pregnant !

Read more-

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