Case Report: Evidence from a salvaged treatment cycle supports an aetiology for the empty follicle syndrome that is related to terminal follicular developmental events

Abstract

Oocyte retrieval in a stimulated in-vitro fertilization treatment cycle was unsuccessful when inadvertently carried out 12 h after the administration of human chorionic gonadotrophin (HCG) injection. Repeat follicular aspiration at 36 h post-HCG injection recovered 20 oocytes, out of which 16 metaphase-II eggs were subjected to intracytoplasmic sperm injection and eight became fertilized. Uterine transfer of three cleaving embryos resulted in a singleton pregnancy which went to term and a healthy female infant was delivered. Our experience shows that in addition to issues of HCG bioavailability to the developing follicles, the temporal relationship between HCG administration (or the luteinizing hormone surge) and follicular aspiration is also an important consideration in the determination of the aetiology of the empty follicle syndrome.

Comparing the efficacy of urinary and recombinant hCG on oocyte/follicle ratio to trigger ovulation in women undergoing intracytoplasmic sperm injection cycles: a randomized controlled trial

“…hCG can act as a surrogate for LH surge to induce final oocyte maturation and ovulation in COH protocols and develop similar periovulatory events such as softening of the connective tissue of follicle which makes easy detachment of oocyte cumulus complex from the follicles wall, hence ease of aspiration [20]. On the other hand, 4-8 h after hCG injection, the cumulus cells become dispersed which leads to cumulus oocyte contact disruption [21].…”

Empty follicle syndrome: the reality of a controversial syndrome, a systematic review

“…The mechanisms responsible for EFS remain obscure, though many hypotheses have been put forward ranging from human error (6,(9)(10)(11) to pharmacologic problems (8,11,12).…”

“…Some hypotheses propose that a possible etiology for GEFS is dysfunctional folliculogenesis, whereby early oocyte atresia occurs with apparently normal hormonal response (13). Furthermore, some patients may need longer exposure to hCG for detachment of oocyte cumulus complexes from the follicular wall (6). However, this theory was challenged by Onalan et al (14), who used a rescue protocol and managed to retrieve oocytes later in the same cycle.…”

“Empty follicle syndrome” after human error: pregnancy obtained after repeated oocyte retrieval in a gonadotropin-releasing hormone antagonist cycle

“…Methods reported to treat EFS have ranged from rescheduling oocyte retrieval (11), administering an additional dose of urinary hCG from a different batch (16,17), and using recombinant hCG (18). Most of the cases of EFS reported so far occurred in GnRH agonist down-regulated cycles, with urinary hCG for final induction of ovulation.…”