Pericentric inversion of chromosome 2 in a patient with the empty follicle syndrome: Case report

Factors associated with oocyte recovery rates during in-vitro fertilization among Nigerian women

Introduction

the availability of oocytes is fundamental to in vitro fertilization (IVF). The factors associated with optimal or suboptimal oocyte recovery rates (ORR) in low-resource settings are not well known. This study aimed to determine the factors associated with ORR by comparing demographic and IVF cycle data of women undergoing IVF in our Centre.

Methods

this was a prospective study of 110 infertile women undergoing IVF at Nisa Premier Hospital, Abuja Nigeria, from October 2020 to September 2021. All women had reached the stage of oocyte retrieval or further, after receiving ovarian stimulation with our routine protocols. Treatment was monitored by serial transvaginal ultrasonography. The oocyte retrieval procedures were performed under conscious sedation, 36 hours after the ovulatory trigger. Optimal ORR was when eggs were obtained from at least 80% of follicles punctured. Sub-optimal ORR was when it was less than 80%. Data analyses utilized SPSS statistical software and a p-value of < 0.05 was considered significant.

Results

the mean age of all women was 34.1±4.9 years. Sixty-nine women (62.7%) had sub-optimal ORR while 41 (37.3%) had optimal ORR. Six women (5.5%) had no oocytes retrieved. Significantly more women with sub-optimal ORR were obese (70.6 vs 29.4%) and had higher follicle-stimulating hormone (FSH) levels (8.11 vs 6.34 miu/ml), p-value- 0.039. Women with sub-optimal ORR had higher mean prolactin levels (17.10 ± 13.93 miu/ml) than women with optimal ORR 11.43 ± 6.65 miu/ml), p-value- 0.019). Significantly more oocytes (5.99 vs 10.37, p-value 0.001), and MII oocytes (5.78 vs 7.56, p-value 0.035) were retrieved in women with optimal than sub-optimal ORR. The duration of stimulation, total amounts of gonadotropins administered, and fertilized oocytes were not significantly different among both groups (p-value >0.05).

Conclusion

this study has shown the factors associated with ORR in our setting to be basal FSH, prolactin, and obesity.

Characteristics of Empty Follicular Syndrome during In vitro Fertilization Embryo Transfer and its Association with Various Etiologies in Comparatively Young Patients

Background:

Nearly 0.6%–7% of patients undergoing in vitro fertilization embryo transfer (IVF ET) will not be able to yield any oocyte despite successful ovarian stimulation and this condition is called as empty follicular syndrome (EFS). EFS is a dreadful situation for clinicians as well as patients, seems to be an unavoidable clinical condition despite a proper ovarian stimulation.

Materials and Methods:

This was a retrospective observational study conducted at a tertiary hospital; 1103 patients who underwent IVF ET between January 2016 and May 2017 were included in the study.

Study Outcome:

To estimate the incidence of empty follicle syndrome (EFS) and to study the associated factors.

Results:

There were 53 (4.8%) cases of EFS out of 1103 cycles of IVF ET; 43 (3.9%) cases were false EFS and 10 (0.9%) cases were genuine EFS. Mean age of EFS group and oocyte retrieved group was 30.17 years and 29.12 years respectively. Recurrence rate of EFS during the next IVF cycle was 36.8%. Decreased ovarian reserve was associated with an increased chance of EFS (54.7%) with a recurrence rate as high as 57%.

Conclusion:

The incidence of EFS is not an uncommon clinical scenario; it depends upon ovarian reserve to a great extent. Young age is not immune for the occurrence of EFS as there is a similar incidence in comparatively younger age group in our study. EFS is seen in all etiological groups of infertility, but only respite is that there is a chance of about 63.2% oocyte retrieval during repeat IVF cycle.

Novel biallelic loss-of-function variants in ZP1 identified in an infertile female with empty follicle syndrome

PURPOSE

Empty follicle syndrome (EFS) refers to the inability to obtain mature oocytes after appropriate ovarian stimulation during the process of in vitro fertilization (IVF). However, the specific cause and mechanism of action underlying EFS remain to be further explored. Herein we aimed to investigate the clinical and genetic characteristics of EFS.

METHODS

After data were collected in an infertile family, we performed whole-exome sequencing (WES) on the patient and confirmed the pathogenic mutations through Sanger sequencing. Western immunoblotting, immunofluorescence staining, and minigene assay were further used to investigate the negative effects of these mutations.

RESULTS

Absence of oocytes was observed over 2 cycles of IVF in the patient, and we evaluated the novel compound heterozygous mutations c.2T>A (p. M1K) and c.1112+1G>T of the zona pellucida glycoprotein 1 gene (ZP1, MIM# 195000) by WES. For the family under study, EFS was classified as an autosomal recessive inheritance pattern. The results of western blotting and immunofluorescence staining analyses confirmed that the missense mutation of c.2T>A [p. M1K] resulted in almost missing protein production. Additionally, using a minigene assay, we demonstrated the deleterious effect on the ZP1 gene of the splice site mutation c.1112+1G>T, which caused truncation of ZP1 protein.

CONCLUSIONS

The compound heterozygous mutations of ZP1 gene identified in this study by genetic and functional experiments constituted a novel genetic cause of EFS, and further study will expand its use in the clinical and molecular diagnoses of EFS.

Evaluation of follicular fluid's Beta-Human chorionic gonadotropin in the follicles of patient undergoing Intracytoplasmic sperm injection: A cross-sectional study

Background

The failure to retrieve oocytes from mature ovarian follicles is referred to as empty follicle syndrome. There is no exact explanation to this problem and it cannot be predicted using ultrasound or serum hormonal levels. The underlying mechanism of Empty follicle syndrome remains obscure.

Objective

In this study, the authors have investigated the relationship between the Beta-Human chorionic gonadotropin ( β HCG) levels in the follicular fluid with or without the oocyte in the follicles of patients undergoing Intracytoplasmic Sperm Injection.

Materials and Methods

Seventy-three infertile couples underwent standard long protocol induction ovulation for Intracytoplasmic sperm injection. On the day of oocyte retrieval, each patient had two samples; follicular fluid including 2-3 follicles with oocyte and follicular fluid including of 2-3 follicles without oocyte were collected in separate tubes. These follicles had similar shape and size. The Samples were transferred to a laboratory for measuring the β HCG level, after which the β HCG levels were compared to the follicles with and without the oocyte in each patient.

Results

In this study, the β HCG level of follicular fluid in the follicles containing oocyte was 18.20 (8.35-42.92) IU/L and in the follicles without the oocyte was 13.50 (5.45-25.81) IU/L. Levels of β HCG in the follicular fluids containing the oocyte were higher than without oocytes, This difference was not statistically significant (p = 0.16).

Conclusion

It seems that the follicular fluid β HCG isn't caused by empty follicle syndrome, and that dysfunctional folliculogenesis may be the cause of this syndrome.

Novel mutation in the ZP1 gene and clinical implications

PURPOSE

Empty follicle syndrome (EFS) is a complex reproductive disorder characterized by the repeated failure to aspirate oocytes from mature ovarian follicles during in vitro fertilization (IVF). In addition to some cases caused by iatrogenic problems and known genetic factors, there are still many unexplained aspects of EFS. Here, we aimed to assess the clinical and genetic characteristics of two EFS patients.

METHODS

We have characterized two primary infertility patients with EFS in a nonconsanguineous family from China. Both the patients presented similar clinical phenotypes, that is a few granulosa cells but no oocytes could be retrieved during repeated cycles with normal follicular development, E2 levels, and bioavailable hCG plasma levels. Abnormal oocytes were obtained once or twice between multiple IVF cycles. We performed Sanger sequencing of the LHCGR and ZP1~ZP4 genes in the patients, and further bioinformatics analysis was performed to identify pathogenic elements in the genes.

RESULTS

A novel mutation, c.181C>T (p.Arg61Cys), and a known mutation, c.1169_1176delTTTTCCCA (p.Ile390Thrfs*16), in the ZP1 gene were both identified in patient 2, but no mutations were identified in patient 1. The novel mutation inherited from her mother was absent in the control cohort and the ExAc database. The arginine residue is conserved at this position, and its replacement by cysteine was predicted to be deleterious. In another allele, a paternal frameshift mutation was predicted to introduce premature stop codons, resulting in the deletion of 234 amino acids from the C-terminus of the ZP1 protein.

CONCLUSIONS

Our findings presented compound heterozygous mutations in ZP1 associated with EFS and abnormal oocytes and provided further new evidence for the genetic basis of EFS and support for the genetic diagnosis of infertile individuals.

Novel Concepts for Inducing Final Oocyte Maturation in In Vitro Fertilization Treatment

Infertility affects one in six of the population and increasingly couples require treatment with assisted reproductive techniques. In vitro fertilization (IVF) treatment is most commonly conducted using exogenous FSH to induce follicular growth and human chorionic gonadotropin (hCG) to induce final oocyte maturation. However, hCG may cause the potentially life-threatening iatrogenic complication "ovarian hyperstimulation syndrome" (OHSS), which can cause considerable morbidity and, rarely, even mortality in otherwise healthy women. The use of GnRH agonists (GnRHas) has been pioneered during the last two decades to provide a safer option to induce final oocyte maturation. More recently, the neuropeptide kisspeptin, a hypothalamic regulator of GnRH release, has been investigated as a novel inductor of oocyte maturation. The hormonal stimulus used to induce oocyte maturation has a major impact on the success (retrieval of oocytes and chance of implantation) and safety (risk of OHSS) of IVF treatment. This review aims to appraise experimental and clinical data of hormonal approaches used to induce final oocyte maturation by hCG, GnRHa, both GnRHa and hCG administered in combination, recombinant LH, or kisspeptin. We also examine evidence for the timing of administration of the inductor of final oocyte maturation in relationship to parameters of follicular growth and the subsequent interval to oocyte retrieval. In summary, we review data on the efficacy and safety of the major hormonal approaches used to induce final oocyte maturation in clinical practice, as well as some novel approaches that may offer fresh alternatives in future.

A Recurrent Missense Mutation in ZP3 Causes Empty Follicle Syndrome and Female Infertility

Empty follicle syndrome (EFS) is defined as the failure to aspirate oocytes from mature ovarian follicles during in vitro fertilization. Except for some cases caused by pharmacological or iatrogenic problems, the etiology of EFS remains enigmatic. In the present study, we describe a large family with a dominant inheritance pattern of female infertility characterized by recurrent EFS. Genome-wide linkage analyses and whole-exome sequencing revealed a paternally transmitted heterozygous missense mutation of c.400 G>A (p.Ala134Thr) in zona pellucida glycoprotein 3 (ZP3). The same mutation was identified in an unrelated EFS pedigree. Haplotype analysis revealed that the disease allele of these two families came from different origins. Furthermore, in a cohort of 21 cases of EFS, two were also found to have the ZP3 c.400 G>A mutation. Immunofluorescence and histological analysis indicated that the oocytes of the EFS female had degenerated and lacked the zona pellucida (ZP). ZP3 is a major component of the ZP filament. When mutant ZP3 was co-expressed with wild-type ZP3, the interaction between wild-type ZP3 and ZP2 was markedly decreased as a result of the binding of wild-type ZP3 and mutant ZP3, via dominant negative inhibition. As a result, the assembly of ZP was impeded and the communication between cumulus cells and the oocyte was prevented, resulting in oocyte degeneration. These results identified a genetic basis for EFS and oocyte degeneration and, moreover, might pave the way for genetic diagnosis of infertile females with this phenotype.

Empty follicle syndrome revisited: definition, incidence, aetiology, early diagnosis and treatment

In this review, the definition, incidence and possible causes of empty follicle syndrome (EFS), including molecular mechanisms that may underlie the syndrome, are discussed, along with prevention and treatment options. EFS is the complete failure to retrieve oocytes after ovarian stimulation, despite apparently normal follicle development and adequate follicular steroidogenesis. Two variants of EFS have been described: the 'genuine' form (gEFS), which occurs in the presence of adequate circulating HCG levels at the time of oocyte aspiration, and the 'false' form (f-EFS), which is associated with circulating HCG below a critical threshold. Heterogeneous HCG concentration thresholds, however, have been used to define gEFS, and to date no standardization exist. The situation is unclear when GnRH-analogues are used for ovulation trigger, as the threshold circulating LH and progesterone levels used to define EFS as 'genuine' are not established. The cause of fEFS has been clearly identified as an error in HCG administration at the time of ovulation trigger; in contrast, the cause of gEFS is still unclear, although some pathogenetic hypotheses have been proposed. Optimal treatment and prognosis of these patients are still poorly understood. Large, systematic multi-centre studies are needed to increase the understanding of EFS.

Karyotype analysis in large sample cases from Shenyang Women's and Children's hospital: a study of 16,294 male infertility patients

To explore that it is necessary to routinely detect chromosomes in infertile patients, we investigated peripheral blood lymphocyte karyotype in 16,294 male infertile patients in the north-east of China and analysed the incidence and type of chromosomal anomaly and polymorphism. G-banding karyotype analysis of peripheral blood lymphocytes was performed in 16,294 cases. Semen analysis was performed three times in all the men. PCR and FISH confirmed the presence of the SRY gene. The rate of chromosomal anomaly in the 16,294 male infertile patients was 4.15% (677/16,294). The rates of chromosomal anomaly were 0.24% in normal semen group, 12.6% in light oligoasthenospermia group, 4.7% in moderate-to-severe oligoasthenospermia group and 9.59% in azoospermia group. There are two male infertile patients with 45,X chromosome karyotype. One X male patient had confirmed the presence of the SRY gene and FISH analysis demonstrated its location on the p arm of chromosome 13. The other X male patient had not found SRY gene in its whole-genome DNA. Meanwhile, sperm motility is slightly oligo-asthenozoospermic at the age of 35-39 and nearly azoospermic at the age of 40-45. As the rates of chromosomal anomaly are 0.24% and 12.6% even in normal semen group and light oligoasthenospermia group, the rates of chromosomal polymorphism are 5.36% and 25.51% in normal semen group and light oligoasthenospermia group, respectively; it is necessary to explore peripheral blood lymphocyte karyotype in all infertile couples. We mentioned that Y, 1, 2, 9 and 12 chromosomes were quite important about male infertility. These findings demonstrate that autosomal retention of SRY can be submicroscopic and emphasise the importance of PCR and FISH in the genetic workup of the monosomic X male. At the same time, it suggested that male infertility might be related to meiotic disturbances with spermatogenetic arrest in Y-autosome translocations, which could result in infertility by reduction of sperm production. Last but not least, ageing is one of the factors that could reduce sperm motility and quality.

Empty Follicle Syndrome: The Possible Cause of Occurrence

OBJECTIVES

Empty follicle syndrome (EFS), although rare, is a disappointing condition in which no oocytes are retrieved from mature follicle after ovulation induction in in vitro fertilization (IVF) cycles. The aim of this study was to estimate the incidence and factors associated with EFS.

METHODS

All cycles resulting in EFS from May 2012 to September 2013 were retrospectively identified at a tertiary referral infertility center. Among the 3,356 cycles performed, 58 (1.7%) women who underwent their first IVF cycle and had no oocyte retrieval were enrolled in the study. Three different stimulation protocols (long, antagonist, and miniflare) were mainly used for induction of follicular growth. Data relating to the age, follicle stimulating hormone (FSH) level, anti-Müllerain hormone (AMH) level, and the number of ampules and follicles for each patient was obtained.

RESULTS

Out of 58 individuals, 10 (17.2%) showed false type and 48 (82.8%) showed genuine EFS. The most frequent findings in our study were diminished ovarian reserve, low anti-Müllerian hormone (AMH; ≤0.5 ng/mL), and less than four mature follicles, indicating EFS in 1.7% of the patients.

CONCLUSION

Low serum AMH levels and a small number of follicles after ovarian stimulation is the manifestation of diminished ovarian reserve. Thus, we suggest that EFS could be a manifestation of low ovarian reserve.

Empty follicle syndrome

Empty follicle syndrome (EFS) is a condition in which no oocytes are retrieved after an apparently adequate ovarian response to stimulation and meticulous follicular aspiration. EFS can be classified into 'genuine' and 'false' types according to hCG levels. It is a rare condition of obscure etiology. The existence of genuine EFS has been questioned and is still controversial. The limitation around EFS is that the definition of EFS is obscure. Management of patients with EFS is a challenge to physicians. No single treatment is known to be universally effective. However, patients should be adequately informed regarding the importance of correct hCG administration because improper hCG administration is a common and preventable cause of EFS. EFS is a syndrome that deserves additional study because such investigation could lead to a further understanding of ovarian biology and infertility.

Empty follicle syndrome: successful treatment in a recurrent case and review of the literature

Empty follicle syndrome is a condition in which no oocytes are retrieved after an apparently adequate ovarian response to stimulation and meticulous follicular aspiration. It is a rare condition of obscure etiology. A patient with primary infertility who underwent seven assisted reproductive technique cycles is described. In spite of a satisfactory ovarian response, aspiration yielded no oocytes in four cycles and 1-4 low quality oocytes in three cycles. In the index treatment cycle, ovulation was triggered using GnRH agonist 40 h prior to ovum pickup and hCG was added 6 h after the first trigger. Eighteen oocytes were recovered, of which 16 were mature and were inseminated by ICSI. Two embryos were transferred 48 h after aspiration and nine embryos were cryopreserved. The patient conceived and delivered a healthy boy at 38 weeks of gestation. The literature is reviewed and possible etiologies and treatment options of this enigmatic syndrome are suggested.

The prevalence of genuine empty follicle syndrome

OBJECTIVE

To describe the prevalence of "genuine" empty follicle syndrome (EFS) and "false" EFS at assisted reproductive technology (ART).

DESIGN

Retrospective cohort.

SETTING

Large private fertility center.

PATIENT(S)

A total of 12,359 patients who underwent ART between 2004 and 2009.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The failure to recover an oocyte during oocyte retrieval at ART, with and without a detectable serum β-hCG on the day of retrieval.

RESULT(S)

Two cases of genuine EFS and nine cases of false EFS were identified in the cohort examined. The prevalence of genuine EFS was 0.016%, and the prevalence of false EFS was 0.072%. Only two out of 11 cases of EFS were considered genuine.

CONCLUSION(S)

Genuine EFS is a rare occurrence. Because this syndrome tends to recur with dismal pregnancy rates at ART, continued identification and further investigation of the syndrome are needed.

Inherited mutation of the luteinizing hormone/choriogonadotropin receptor (LHCGR) in empty follicle syndrome

OBJECTIVE

To test by genomic analysis whether empty follicle syndrome (EFS) in a family with two affected sisters has a genetic basis.

DESIGN

Whole-exome sequencing in the context of clinical genetics.

SETTING

University hospital.

PATIENT(S)

Two women (36 and 32 years old at the time of the study) with EFS.

INTERVENTION(S)

Genetic counseling based on autosomal recessive inheritance.

MAIN OUTCOME MEASURE(S)

Discovery of a mutation in the LH/choriogonadotropin receptor (LHCGR) as the cause of EFS.

RESULT(S)

A novel missense mutation in LHCGR, p.N400S, was homozygous in sisters with EFS and/or infertility, but not in their unaffected siblings or parents. The mutation was not present in 500 ancestry-matched control subjects. Asparagine at residue 400 is highly conserved and its substitution by serine predicted to alter critical interactions that stabilize LHCGR.

CONCLUSION(S)

We describe a genetic basis for EFS and provide strong evidence for the existence of genuine EFS in some patients. A mutation impairing the function of LHCGR explains the lack of response of these patients to repeated administration of β-hCG.

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

OBJECTIVES

To examine all case reports and studies of empty follicle syndrome (EFS) that have been published since the condition was first reported, in an attempt to identify trends or common features that may expose possible risk or causative factors.

DESIGN

Systematic review of all available literature obtained from PubMed, Ovid, and Embase.

SETTING

Academic unit.

PATIENT(S)

Review of all published case reports and case studies.

INTERVENTION(S)

All original work was assessed and labeled as "genuine" or "false" EFS according to set definitions.

MAIN OUTCOME MEASURE(S)

Genuine and false EFS. We defined genuine EFS as a failure to retrieve oocytes from mature ovarian follicles after ovarian stimulation for IVF after apparently normal follicular development and steroidogenesis in the presence of optimal beta-hCG levels on the day of oocyte retrieval. False EFS included all cases in which this definition cannot apply and often in which human error or a pharmaceutical inaccuracy has occurred.

RESULT(S)

By classifying all cases of EFS as "genuine" or "false" according to stated definitions, it was evident that a much greater proportion of cases of reported EFS, 67%, occurred as a result of human error and that "genuine empty follicle syndrome" is an even rarer event than previously presumed.

CONCLUSION(S)

Our report highlights the value of classifying cases of EFS as "genuine" or "false" and shows that more epidemiological data are required of "genuine" EFS cases to develop a clearer picture of the possible etiology.

[The follicular flushing duplicate the pregnancy rate on semi natural cycle IVF]

OBJECTIVE

To evaluate the importance of follicular flushing on semi natural cycle IVF.

MATERIAL AND METHODS

We have compared prospectively the reproductive potential of oocytes obtained from follicular fluid (LF, N = 79) to those obtained from follicular flushing (R, N = 47) in 146 oocyte pick ups.

RESULTS

The group LF and R were similar with regard to fertilization rate (79.7 versus 88.1%, respectively), percentage of superior grade embryos (28.8 versus 37.8%) and implantation rate (24.1 versus 44.1%).

CONCLUSION

The practice of follicular flushing on semi natural IVF cycle improves the pregnancy rate. The oocytes obtained by follicular flushing had the same reproductive potential than those obtained on follicular fluid.

Transcriptional profiling of granulosa cells from a patient with recurrent empty follicle syndrome

Empty follicle syndrome (EFS) is characterized by the absence of oocytes after apparently normal follicular development and the pathogenesis of this syndrome is not well characterized. The aim of this study was to analyse whole gene expression of granulosa cells (GC) from a patient with recurrent EFS by using Affymetrix GeneChip. A total of 160 genes were identified as being differentially expressed (by at least two-fold) between EFS GC and the control GC. Most of the differentially expressed genes were involved in cell growth and death. Among these were MAPK3, which plays an important role in the inhibition of apoptosis, was down-regulated 2.3-fold in EFS GC. Moreover, secretory phospholipase A2 and transforming growth factor receptor II, key regulators of cell death pathway, were down-regulated 3.54- and 2.82-fold respectively in EFS. Gene expression of granulosa cells from the EFS patient was significantly altered. The absence of the oocytes might be due to the increased apoptotic gene expression and the reduction of transcripts whose products are responsible for healthy follicular growth. Gene expression analyses might be a useful technique in identifying markers to follow a healthy follicular maturation and understanding the events that lead to EFS.