Empty follicle syndrome: Case series and review of literature

Abstract

Background: Failure to aspirate oocytes from apparently normally growing ovarian follicles with normal steroidogenesis after ovarian stimulation and meticulous follicular aspiration is referred to as empty follicle syndrome (EFS).There are two types of EFS, namely genuine (GEFS) and false (FEFS). It is a rare condition of obscure etiology. EFS does not predict reduced fertility potential in future cycles although it can recur due to a biological abnormality in the availability of mature oocytes that are retrievable. A case series of 12 patients of EFS is described here. The literature has been reviewed and definition, prevalence, risk factors, etiopathogenesis, and therapeutic approaches are discussed here. Objective: To assess the prevalence, identify the risk factors, and management options for GEFS. Design and Setting: This retrospective, observational study was conducted at the Institute of Reproductive Medicine, Madras Medical Mission Hospital, Chennai, India. All patients who had no oocytes retrieved in in vitro fertilization (IVF) treatment cycles from January 2014 to December 2015 were included and oocyte donation cycles were excluded from the study. All patients were stimulated by antagonist protocol, EFS cycles were identified, and then demographic variables and ovarian hyperstimulation strategies were evaluated. Methods: A literature search was undertaken using the phrase empty follicle syndrome in PubMed and several studies and case reports were identified. Results: Among 860 IVF cycles, 18 were identified as EFS cycles. Of the identified EFS cycles, 14 had genuine and 4 had FEFS. The reason for the occurrence of FEFS in this study was premature ovulation. The prevalence of GEFS at our center during the study period was 2.09% (18 Χ 100/860) and the rate of recurrence of GEFS was 100%. Conclusion: Accurate timing of final oocyte maturation, properly scheduled ovarian hyperstimulation, instructions to the patients, and full workup for IVF are essential for the successful recovery of oocytes. We assert that GEFS as an entity exists and confirm that patients with EFS present a real challenge to manage. No factors have been identified in this study which can predict EFS, unlike in literature. Furthermore, it was also found that no single treatment strategy is universally effective.