Fig. 26.1
Management of empty follicular syndrome
Step 1: If it is noticed that there is no oocyte in the first ovary, it is prudent to pause the oocyte retrieval and check for any technical problems.
Step 2: If technical problems have been ruled out, the clinician should try to look for premature ovulation, which is evident by presence of fluid in the pouch of Douglas. The clinician can proceed to retrieve the follicular fluid from the other ovary, but the chance of finding an oocyte is minimal. The patient could be counselled for oocyte donation cycle, and if willing, the embryo transfer can be done.
Step 3: If there is no free fluid in the pouch of Douglas, one should proceed to do urine pregnancy test or check levels of beta HCG in serum. Serum levels might take time, and hence the more practical approach would be to do a urine pregnancy test.
Step 4: If the urine test shows negative result or serum beta HCG is low, then the patient should be administered rescue dose of HCG and plan to proceed with the completion of procedure after 24 h.
Step 5: If the urine test is positive or the serum beta HCG levels are normal, then the procedure should be completed in the same sitting. The chances of finding oocytes in the other ovary are minimal. Remedial action in such a case is to proceed to an oocyte donation or change protocols in the next ovarian stimulation cycle.
The following steps would be taken in the next cycle:
1.
Shift from antagonist to agonist or vice versa
2.
Shift from urinary preparation to recombinant preparations of gonadotropins
3.
Use of recombinant HCG for trigger
4.
Change the manufacturer of the batch the HCG used
Step 6: In case of genuine EFS, oocyte donation remains the only option.
26.6.2 R-HCG—A Novel Entrant
r-HCG has been an important part in the science of assisted reproduction. Recombinant product has highest purity, increased bioavailability and decreased batch-to-batch variation. With these qualities, r-HCG would go a long way in eliminating the variations caused due to urinary derived HCG and hence may help us eliminate EFS. There have been reports of successful outcome in cases of previous failures with urinary HCG.
26.6.3 Role of Oocyte Donation
Oocyte donation remains the only hope of treatment in cases of genuine EFS. The couple should be counselled for the same especially after repeated failures. Needless to say, the donor and the recipient should be matched, and the donation should be carried out according to the rules of the land.
26.7 Conclusion
EFS is a definite entity, and the clinicians would definitely see the cases of the same in the clinical practice. It is a highly stressful situation for both the couple undergoing the treatment and the clinical team, and hence it is necessary to take steps to prevent it and apply step-by-step formula to minimize it or its occurrence.
Even though EFS has been reported in both natural and unnatural cycles, it is very unlikely that it reoccurs. However, a history of recurrent EFS makes it mandatory to change treatment protocols to prevent it. Due to multiple aetiologies and confounding theories towards development, the definitive treatment of EFS still remains an enigma. Appropriate monitoring, tailoring of drugs and their dosages, managing the time gap interval between HCG dosage and oocyte retrieval and avoiding technical mishaps go a long way in preventing this repetitive situation. Further work and research is needed to identify, diagnose and treat these patients to manage and prevent the EFS and carve a successful path to achieve parenthood.
References
1.
Coulam CB, Bustillo M, Schulman JD. Empty follicle syndrome. Fertil Steril. 1986;46(6):1153–5.PubMed
2.
Driscoll GL, Tyler JP, Knight DC, Cooke S, Kime L, Clark L, Bernstein J. Failure to collect oocytes in assisted reproductive technology: a retrospective study. Hum Reprod. 1998;13(1):84–7.CrossRefPubMed
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