Empty Follicle Syndrome (EFS) is a syndrome that can only be diagnosed after going through an IVF/ICSI cycle and doing the oocyte (egg) retrieval. The aspirated follicles contain no oocytes or oocytes of very poor quality although everything seemed optimal on the ultrasound during ovulation monitoring. In many cases of unexplained infertility this is finally a diagnosis. It is a rare condition with unknown etiology.
What is empty follicle syndrome?
Empty follicle syndrome is a condition which can only be diagnosed after an IVF/ICSI cycle with subsequent oocyte retrieval. During the monitoring phase of taking ovulation inducing medication and following up through ultrasound sonography everything seems to be progressing well only to find all the seen follicles empty or of very poor quality after aspiration. These patients usually do not complete the cycle with an embryo transfer. The etiology of this syndrome is unknown, but a few theories will be discussed below.
Reasons for empty follicles
0.5% to 2% of women suffer from cycles where during ovulation no oocyte grows within the follicle or an oocyte with bad quality that would not be suitable for fertilization grows. This could be a recurrent or transient situation. Many women after a cycle where the follicles retrieved were empty or of poor-quality show better results in subsequent cycles.
1- Premature ovulation
There is a group of patients where ovulation occurs earlier than expected after the injection of Human Chorionic Gonadotrophin (HCG). After an injection of HCG, the ovum (egg) pickup should be scheduled after 36 hours, sometimes after a timely retrieval and an ultrasound that indicates a good number of follicles. After retrieval these follicles turn out to be empty an early ovulation should be considered.
2- Genetic factors
A theory is that empty follicle syndrome could have a genetic factor, families with several couples suffering from unexplained infertility especially when chromosomal testing has been done and turned out normal, could be explained by empty follicle syndrome.
3- Medicine Error
IVF/ICSI cycles depend on an exact and timed medicine schedule any errors in preparing or injecting the medication could have consequences on the overall cycle results and cause empty follicles. Most important of all the HMG which is the main medicine deciding the exact ovum (egg) pickup time.
4- Drug storage error
The injections given for ovulation stimulation should be kept in the refrigerator door under certain temperatures. Ovulation inducing medication consist of hormones that degrade fast under wrong storage circumstances and temperature and could affect the quality of eggs negatively or cause follicles to grow empty. Ask your doctor or pharmacist about the correct storage methods to keep the effect of your medication optimal.
5- Wrong medicine intake
Ovulation stimulation medication are mainly injections. Confusion about taking them subcutaneously, intramuscular or maybe the fear of self-injecting might cause the patient to administer it wrongly compromising their effect.
Diagnosis of empty follicle syndrome
Empty follicle syndrome unfortunately can’t be diagnosed until after the oocyte (egg) retrieval. The patient shows a good hormone profile before starting her IVF/ICSI cycle, during the stimulation period her ultrasound shows good results with good follicle numbers and growth and her E2 numbers show a good rise in her blood tests. On the day of her oocyte retrieval procedure the aspirated follicles are empty not containing any oocytes (eggs) or poor-quality ones.
How to treat empty follicle syndrome?
Scientists and doctors till now have only come up with theories as to what the reasons are behind Empty Follicle Syndrome, so the treatment or prevention of it in future cycles is still in an experimental phase. Thorough explanation on drug storage, intake and times should be given to avoid any mistakes or confusion. A regimen of supplements that improve the sensitivity of the ovaries are given for 2 to 3 months before another IVF or ICSI trial is done hopefully with better outcomes.
