Evidence of 'genuine empty follicles' in follicular aspirate: a case report

Risk factors, management, and future fertility of empty follicle syndrome: a retrospective study with real-world data

Background

Empty follicle syndrome (EFS) is a challenging clinical problem. This study aims to identify the risk factors for EFS, to present pregnancy outcomes in both EFS cycle as well as subsequent cycles, and to summarize an effective rescue protocol to improve outcomes.

Methods

A retrospective analysis between 2016 and 2020 was conducted at our center. Stricter criteria were applied to diagnose EFS. Logistic regression analysis was used to identify the risk factors for EFS. Further analyses were performed within the EFS cycle to present pregnancy outcomes and to find optimal rescue protocols. Long-term follow-up was conducted until live birth was achieved, covering at least two complete oocyte retrieval cycles.

Results

Among 14,066 patients, 54 (0.38%) were identified as EFS. Patients with polycystic ovary syndrome (PCOS) had a significantly higher risk of developing EFS than non-PCOS ones (aOR = 2.67; 95% CI, 1.47 to 4.83). Within EFS patients, delaying the second oocyte retrieval by 3-6 h significantly improved the rates of obtaining oocyte (97.4% versus 58.3%, P = 0.002), getting embryo available for transfer (92.3% versus 33.3%, P < 0.001), and pregnancy (48.7% versus 8.3%, P = 0.017) compared to other delayed retrieval times. Overall, 31.5% (17/54) and 46.7% (7/15) EFS patients achieved live birth in the EFS cycle and the future cycle, respectively.

Conclusions

PCOS is an independent risk factor for EFS, indicating that longer exposure time to human chorionic gonadotropin (hCG) may be necessary. Delaying the second oocyte retrieval by 3-6 h is an effective rescue protocol for EFS patients to achieve optimal outcomes. EFS in a single cycle does not necessarily indicate future fertility decline, but repeated EFS may result in poor outcomes.

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.

The importance of follicular flushing in optimizing oocyte retrieval

PURPOSE OF REVIEW

To critically evaluate the use of follicular flushing during oocyte retrieval.

RECENT FINDINGS

The latest meta-analysis evaluating follicular flushing does not favour its use over single aspiration. The randomized controlled trials (RCTs) included, however, are characterized by significant heterogeneity regarding the population analysed, the needle type and lumen used, the aspiration pressure applied and the number of flushing attempts performed. More importantly, information regarding the flow rate used for aspiration is scarce. The only RCT employing a constant flow rate between single aspiration and follicular flushing in women with monofollicular development, suggests that a higher number of oocytes is retrieved after follicular flushing.

SUMMARY

In order to eliminate clinical heterogeneity that might obscure the detection of the true effect of follicular flushing, randomization to single aspiration and follicular flushing should occur within the same patient. This can be achieved by randomly allocating each patient's ovary to either single aspiration or follicular flushing, maintaining similar flow rates between the groups compared.Given the importance of maximizing the number of oocytes retrieved from a given number of follicles developed, the conduction of properly designed RCTs evaluating follicular flushing is certainly required.

Antral follicle count, oocyte production and embryonic developmental competence of senescent Nellore (Bos indicus) cows

Information on the follicular population and oocyte quality of cows in the final period of reproductive life is scarce. The present study aimed to compare the antral follicle count (AFC), oocyte production and embryonic developmental competence of young versus long-lived and senescent Bos indicus beef cows. Nellore cows (Bos indicus) were classified into three groups according to age: young (4-9 years, n = 10), long-lived (14-17 years, n = 10) and senescent (17-23 years, n = 10). At a random time in the estrus cycle, the cows received cloprostenol sodium salt (0.5 mg, IM), estradiol benzoate (1 mg, IM) and an intravaginal P4 device (1.4 g). Five days later, the P4 devise was removed and oocyte collection (OPU1) was performed. A second OPU (OPU2) was performed 5 days after the first in order to aspirate only growing follicles. During each OPU, AFC and the number and quality of cumulus-oocyte complexes (COCs) were evaluated. Then, the COCs were placed in standard maturation medium (IVM), fertilized and incubated for 9 days. The data were subjected to ANOVA and Multinomial Logistic Regression. The AFC was smaller in long-lived and senescent cows in both OPU1 and OPU2 when compared to younger cows. There was no difference in AFC between OPU1 (19.9 ± 1.8) and OPU2 (17.6 ± 1.9) in young cows, however, more follicles were punctured in long-lived and senescent cows in OPU1 (12.0 ± 2.6 and 19.3 ± 4.6) than in OPU2 (9.2 ± 1.9 and 10.3 ± 2.3), respectively (P < 0.01). The numbers of COCs recovered from young cows (OPU1 = 14.2 ± 1.8; OPU2 = 8.4 ± 0.9) were higher than those obtained from long-lived cows (OPU1 = 5.9 ± 2.3; OPU2 = 4.3 ± 1.0) and senescent cows (OPU1 = 7.2 ± 3.0; OPU2 = 4.1 ± 1.7), respectively (P < 0.05). The cleavage rate did not differ between groups. However, the rate of blastocyst formation was higher for young (64.8%) and long-lived (65.0%) compared to senescent (16.5%) cows (P < 0.01). In conclusion our results indicate that the AFC is lower in long-lived and senescent cows compared with young cows. However, unlike in senescent cows, the embryonic development of long-lived cows is similar to that of young cows. This suggests that Nellore cows aged >17 years begin to have reduced embryonic development capacity due to ovarian aging.

Borderline form of empty follicle syndrome treated with a novel dual trigger method combined with delayed oocyte retrieval: A case report

BACKGROUND

Borderline form of empty follicle syndrome is a condition in which only a few mature or immature oocytes are recovered after meticulous follicular aspiration, despite adequate ovarian response to stimulation. It is a rare phenomenon with an unclear cause. Currently, the condition still lacks effective treatment.

CASE SUMMARY

A patient with secondary infertility who had undergone three cycles of assisted reproductive technique (ART) is described. With regard to good follicular response, two oocytes were obtained in the first two ART cycles, but no embryo was formed. In the third ART cycle, which is the subject of this study, ovulation was induced by dual trigger of a supernormal dose of human chorionic gonadotropin (HCG) combined with a delayed oocyte retrieval approach. The method involved administration of gonadotropin-releasing hormone agonist, recombinant HCG, and urinary HCG 39 h before ovum pick-up. Ten oocytes were recovered, two out of three mature eggs were fertilized after intracytoplasmic sperm injection, resulting in two embryos that were subsequently cryopreserved. The case report guidelines have been used herein to present the first case of this novel dual trigger method.

CONCLUSION

This approach provides a new treatment option for patients with a similar condition in the future. This study can also inspire further investigation on the effects of various β-HCG serum levels 36 h after intramuscular HCG administration.

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.

In vivo transplantation of 3D encapsulated ovarian constructs in rats corrects abnormalities of ovarian failure

Safe clinical hormone replacement (HR) will likely become increasingly important in the growing populations of aged women and cancer patients undergoing treatments that ablate the ovaries. Cell-based HRT (cHRT) is an alternative approach that may allow certain physiological outcomes to be achieved with lower circulating hormone levels than pharmacological means due to participation of cells in the hypothalamus-pituitary-ovary feedback control loop. Here we describe the in vivo performance of 3D bioengineered ovarian constructs that recapitulate native cell-cell interactions between ovarian granulosa and theca cells as an approach to cHRT. The constructs are fabricated using either Ca++ or Sr++ to crosslink alginate. Following implantation in ovariectomized (ovx) rats, the Sr++-cross-linked constructs achieve stable secretion of hormones during 90 days of study. Further, we show these constructs with isogeneic cells to be effective in ameliorating adverse effects of hormone deficiency, including bone health, uterine health, and body composition in this rat model.

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.

Is the time interval between HCG administration and oocyte retrieval associated with oocyte retrieval rate?

The aim of this study was to evaluate whether prolongation of the time interval between HCG administration and oocyte retrieval, from 36 h to 38 h, affects oocyte retrieval rate in women undergoing ovarian stimulation with gonadotrophins and GnRH antagonists for IVF. One hundred and fifty-six normo-ovulatory women were randomized to have oocyte retrieval performed 36 h (n = 78) or 38 h (n = 78) following HCG administration. Oocyte retrieval rate was defined as number of cumulus-oocyte-complex (COC) retrieved/follicle ≥ 11 mm present on day of HCG administration. No significant differences were observed between the groups regarding baseline characteristics. Moreover, no significant difference was observed between the groups regarding oocyte retrieval rate (difference: + 1.2%, 95% CI for difference between medians: -4.5 to +12.1). The median (95% CI for the median) was not significantly different between the groups regarding number of cumulus-oocyte-complexes (COCs) retrieved: 5.5 (5.0-7.0) versus 6.0 (5.0-6.2), respectively, and fertilization rates: 57.7% (50.0-66.7) versus 50.0% (44.8-65.5), respectively. Live birth rates were similar between the groups (20.5% versus 16.7%, RD: + 3.8%, 95% CI: -8.5 to +16.1, respectively). Prolongation of time interval between HCG administration and oocyte retrieval from 36 h to 38 h does not affect oocyte retrieval rate.

Failure of intrauterine insemination as rescue treatment in low responders with adequate HCG timing with no oocytes retrieved

In this retrospective study, the efficiency of carrying out rescue intrauterine insemination (IUI) in low-responder patients undergoing IVF when no oocytes were retrieved after follicular aspiration and when HCG timing was adequate was analysed. A historical control group was used. Over 13 years, women undergoing IVF with failure to obtain oocytes at follicular aspiration underwent rescue IUI if the following criteria were met: adequate HCG timing; one normal tube; motile sperm count after preparation over 3 million/ml; and ultrasound visualization of one to six follicles over 13 mm. The rescue IUI was carried out 1 h after follicular aspiration. Results were compared with those of a standard IUI population (5394 cycles) in the same period. Confidence intervals were calculated using Poisson 97.5% confidence upper tail limits when no event was observed in the study sample. No pregnancies were achieved among the 54 cases who underwent rescue IUI (confidence interval: 0 to 6.8%). This pregnancy rate was lower than that observed in the general IUI population (17.5%) (relative risk, 19.2). After adjusting for age and endometriosis, the relative risk was 11.7. The rescue IUI is an inefficient procedure. Its efficacy is unlikely to exceed 7% pregnancy rate per IUI.

A case of empty follicle syndrome who conceived after aspiration of an endometrial cyst

Empty follicle syndrome (EFS) has been defined as a condition where no oocytes can be retrieved for in vitro fertilization (IVF) even though ultrasound findings and estradiol (E₂) levels suggest the presence of potential follicles. The EFS is a rare condition with an incidence of 0.5-7 % of women undergoing IVF treatments. Although there are many hypotheses as to the cause of EFS, including advanced ovarian age, drug-related problems, and dysfunctional folliculogenesis, its cause remains unknown. A 37-year-old woman with endometriosis and a 5-year history of primary infertility underwent IVF treatment for 4 cycles. No oocytes were retrieved in 2 cycles and no fertilized eggs were obtained in the other 2 cycles. We assumed that endometriosis adversely affected folliculogenesis and fertilization. Aspiration of an endometrial cyst in the right ovary and subsequent administration of oral contraceptives resulted in successful folliculogenesis and fertilization. Thereafter, she conceived and delivered a 2,662 g female infant at 38 weeks of gestation. Here, we report a case of EFS who conceived in the 5th IVF cycle after aspiration of an endometrial cyst. We assumed that endometriosis might have been involved in the dysfunction of folliculogenesis and EFS.

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.

Does empty zona pellucida indicate poor ovarian response on intra cytoplasmic sperm injection cycles?

The factors behind the empty zona pellucida (EZP) formation and its relationship with in vitro fertilization (IVF) outcomes were analyzed. A total of 104 patients who underwent IVF treatment and collected oocytes including EZP were enrolled in this study. EZP index (EZPI = the ratio of number of EZP to number of cumulus-oocyte complex (COC)) was used for the statistical analysis. Patients were grouped as Group 1 when EZPI ≤ 0.17 (n = 57) and Group 2 when EZPI > 0.17 (n = 47). Type-2 EZP, a variation or an advanced type of oocyte degeneration, is tested. Woman age, basal hormone levels, and total gonadotropin dose were significantly higher in Group 2 compared to Group 1. Total antral follicle count was significantly low in Group 2. Total number of mature oocytes, oocyte quality index, the number of fertilized oocytes, and the numbers of Grade 1 embryos were significantly low in Group 2. On the linear regression analysis, using gonadotropin releasing hormone antagonist protocol (B = 0.086, p = 0.030), the number of ≥17 mm follicle (B = 0.015, p = 0.047), peak serum level of estradiol (B = -3.625; p = 0.014), number of fertilized oocytes (B = -0.02, p = 0.0001) and the day-2 embryo score (B = -0,044, p = 0.001) significantly affected EZPI. An increment of the EZPI may be revealed decreased oocyte quality, and it is also related to the poor ovarian response.

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.

mTOR kinase inhibition results in oocyte loss characterized by empty follicles in human ovarian cortical strips cultured in vitro

OBJECTIVE

To determine whether oocyte loss is induced by mTOR kinase inhibition in human cortical strips as seen in model organisms in vivo and in vitro.

DESIGN

Ovarian cortex was collected at two centers and cut into small strips. Strips were cultured for 6 days with or without the mTOR inhibitor rapamycin (RAP; 100 nM). Strips were then embedded in paraffin, and serial sections were prepared.

SETTING

Samples were collected in general obstetric (Edinburgh), gynecologic surgery (New Haven), and fertility preservation assisted reproductive technology (ART) (New Haven) practices.

PATIENT(S)

Ovarian cortex collected from patients (15-34 years of age) during cesarean section (donated tissue) was removed for the purposes of fertility preservation or was prepared after oophorectomy.

INTERVENTION(S)

Tissue was used for research purposes only, with no subsequent patient intervention.

MAIN OUTCOME MEASURE(S)

Follicles were counted and assessed in each serial section. Caspase activity was monitored to determine whether mTOR inhibition activated apoptosis.

RESULT(S)

The RAP inclusion in cultures results in significantly fewer follicles compared with ethanol vehicle-treated controls. Furthermore, RAP treatment resulted in the induction of follicles that lacked an oocyte in any serial section (30/161 follicles vs. 1/347 ethanol vehicle-treated follicles). Caspase activity was not elevated by RAP treatment.

CONCLUSION(S)

mTOR inhibition results in a conserved destruction of the oocyte by adjacent granulosa cells (GC) in the absence of increased caspase activity. This model of oocyte loss is not consistent with classic apoptosis/atresia.

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.