CONTROVERSIES OF EMPTY FOLLICULAR SYNDROME

The mechanism of EFS is not well known, though many hypothesis have been put forward,
ranging from human error to pharmacological problem67,68. From studying literature review it
is evident that EFS exist in two forms i.e. false EFS and genuine EFS. Some hypothesis
propose that a possible etiology for EFS is dysfunctional folliculogenesis, where early oocyte
atresia occur with normal hormonal response 69. Some patients may need longer exposure to
hCG for oocyte retrieval. Onalan et al. challenged this theory and need rescue protocol to
retrieve oocyte at later stage in some cycle 70. Which is now known as fEFS.
Others have hypothesised that EFS result from advanced ovarian ageing, through altered
folliculogenesis. It is also thought that granulosa cell function in older women may lead to
altered oocyte growth and maturation and lead to EFS. Some have proposed that genetic
factors could be responsible for some causes of EFS 71,72.
To conclude a distinction between gEFS and fEFS is clearly mentioned in studies but EFS
does not represent permanent pathology because many cases occur sporadically. The relative
small risk of occurrence of gEFS and even smaller risk of reoccurrence indicates that it is
chance finding rather than cause of infertility 70. Adequate timing of hCG, identifying patients
with poor ovarian response to ovarian hyper stimulation and a clear communication and
instructions between both IVF team and patients are mandatory to reduce chances of EFS.
Registering all cases of gEFS would help to find a proper etiology and a better treatment.

MATERIAL AND METHOD

STUDY DESIGN

Retrospective case series with a systematic review.

METHODOLOGY

All cycles resulting in EFS from 2004 to 2019 in ART clinic of ninewells hospital, Dundee
Scotland were retrospectively studied between may 2020 and July 2002. Ninewells ACU
provide treatment for both NHS and self funded patients.it. It was established in 1980s and
developed into one of the largest centers in Scotland.

Data collection and subject :

Approval from caldicott was taken before starting the study to protect any information that
could identify a patient and the information is only shared when it is appropriate to do so.
Data was provided by Dr. Vanessa Kay (consultant gynaecologist, ninewells ACU). The
patients were chosen from case records of ART unit who were identified as empty follicular
syndrome , i.e. those marked by absence of oocytes from the mature follicle following
ovulation induction.

Inclusion or exclusion criteria :

 Women attending ART Unit in ninewells undergoing IVF, ICSI and egg donors
having been identified as empty follicular syndrome.
  Those with complete IVF, ICSI cycle and egg donors records, with a complete
clinical history.
 woman who have signed that they agree that data from their treatment can be used for
audit/research on HFEA Disclosure of Information form.

Subjects who met inclusion criteria were included. Two stimulating methods were used for
follicular growths in cycles. In long protocol ovaries were suppressed by Buserelin
( gonadotrophin-releasing hormone analog (GnRH-a) ), starting in mid luteal phase of
previous menstrual cycle, followed by ovarian stimulation using recombinant follicle-
stimulating hormone (rFSH) gonal-f or human menopausal gonadotrophin menopur. Trans
vaginal ultrasound was used to monitor follicular growth. When follicular size reached >11
mm recombinant hCG (rhCG) Ovitrelle was administered.

In antagonist protocol rFSH menopur was given on 2nd day of menstrual cycle and follicular
growth was monitored using trans vagina ultrasound. Antagonist ganerelix was administered
when follicular size was >11 mm on trans vaginal ultrasound. In on patient antagonist
centroids was administered when follicular size was > 11 mm. When size of follicle was
optimum rhCG was administered and oocyte retrieval was carried out 34-36 hours later.

All the data including age, BMI, duration of infertility, type of infertility, semen analysis,
treatment, number of follicles formed, number of cycles, number of embryo transferred and
results were collected and presented using appropriate statistical analysis were presented in
tables.

RESULTS FROM NINEWELLS DATA

All cycles resulting in EFS from 2004 to 2019 in ART clinic of ninewells hospital, Dundee
Scotland were retrospectively studied between may 2020 and July 2002. Ninewells ACU
provide treatment for both NHS and self funded patients.it. It was established in 1980s and
developed into one of the largest centers in Scotland. With the following success rates in year
2015 :

Age Success rate Success rate % National average

<35 yrs 93/193 48% 41%
35-37 yrs 23/87 26% 34%
38-39 yrs 13/55 24% 26%
40-42 yrs 5/28 18% NA

Since 2004 till 2019 four patients with empty follicular syndrome were identified.

Patient Age BMI Duration AMH Type of Number Number

of treatment of of
infertility follicles oocyte
 (Months) collected
Patient 1 36 30 24 13.2 IVF with donor 2 0
sperm
Patient 2 41 28.4 36 3.5 IVF 1 0
Patient 3 33 25.2 24 3.34 IVF 2 0
Patient 4 35 21.4 12 1.45 IVF with donor 2 0
sperm
Patient 5 28 29 23 <1 ICSI 1 0

In all the patients no oocytes were collected therefore, no embryo was formed and transferred
in any of the patient. In addition to above data partner of patient 5 was suffering from severe
oligospermia. Indication for choosing ART is mentioned below:

 Patient 1 – same sex couple

 Patient 2 – unexplained infertility
 Patient 3 – unexplained infertility
 Patient 4 – same sex couple
 Patient 5 – male factor infertility

RESULTS FROM HFEA DATA

Fig 1 : TOTAL NUMBER OF IVF CYCLES CARRIED OUT EVERY
YEAR FROM 2009 TILL 2018 IN UK

IVF cycles
3500

3000

2500

2000
Axis Title

1500

1000

500

0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Fig 2 – Number of fresh oocytes collected

Fig 2a : Fresh Oocytes Collected in Year 2009

 2009
16000
14000
12000
10000 2009
8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20

Fig 2b : Fresh Oocytes Collected in Year 2010

2010
16000
14000
12000
10000
2010
8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20
 Fig 2c : Fresh Oocytes Collected in Year 2011

2011
18000
16000
14000
12000
10000 2011

8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20

Fig 2d : Fresh Oocytes Collected in Year 2012

2012
18000

16000

14000

12000

10000 2012

8000

6000

4000

2000

0
01-May 06-Oct Nov-15 16-20 >20
 Fig 2e : Fresh Oocytes Collected in Year 2013

2013
18000
16000
14000
12000
10000 2013

8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20

Fig 2f : Fresh Oocytes Collected in Year 2014

2014
18000

16000

14000

12000

10000 2014

8000

6000

4000

2000

0
01-May 06-Oct Nov-15 16-20 >20
 Fig 2g : Fresh Oocytes Collected in Year 2015

2015
18000
16000
14000
12000
10000 2015

8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20

Fig 2h : Fresh Oocytes Collected in Year 2016

2016
18000
16000
14000
12000
10000 2016

8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20
 Fig 2i : Fresh Oocytes Collected in Year 2017

2017
18000
16000
14000
12000
10000 2017

8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20

Fig 2j : Fresh Oocytes Collected in Year 2018

2018
18000
16000
14000
12000
10000 2018

8000
6000
4000
2000
0
01-May 06-Oct Nov-15 16-20 >20

The year wise trend of fresh oocytes collected, range bound, seen maximum in
06-10 oocytes (approx 14000), followed by 11-15 oocytes (approx 10000), then
01-15 oocytes (approx 9000), 16-20 oocytes (approx 4000), more than 20
oocytes (approx 3000), for the following 2009, 2010, 2011, 2012, 2013, 2014,
2015, 2016 and 2018 years

Fig 3 : Oocytes collected in years 2009-2018

Fig 3a : 1-5 OOCYTES COLLECTED IN YEARS 2009 - 2018

01-May
16000

14000 13514 13221

12930 12719
12136
12000 11375 11303 11463
10972
10205
10000
01-May
8000

6000

4000

2000

0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Fig 3b : 6-10 OOCYTES COLLECTED IN YEARS 2009 - 2018

 06-Oct
16500 16304 16283
16063 16080
16000
15672 15649 15629
15583
15500
15109
06-Oct
15000

14551
14500

14000

13500
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Fig 3c : 11-15 OOCYTES COLLECTED IN YEARS 2009 - 2018

Nov-15
11500
11108
10892 10937 10968 11031
11000 10852 10851
10675
10500 Nov-15
10169
10000
9727

9500

9000
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Fig 3d : 16-20 OOCYTES COLLECTED IN YEARS 2009 - 2018

 16-20
6000
5411 5526 5513
5159 5271 5244 5205
5078
5000 4745
4429

4000
16-20
3000

2000

1000

0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Fig 3e : >20 OOCYTES COLLECTED IN YEARS 2009 - 2018

>20
4500
4006 4117
4000
3690
3564
3500
3203 3158
2882 2943 2939
3000
2614
2500 >20

2000

1500

1000

500

0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
 Fig 4:trend in percentage of oocytes collected every year

0.4

0.35 0.35
0.34 0.34 0.34
0.34 0.34
0.33 0.33
0.32 0.32
0.3

0.27
0.26 0.27 0.26
0.25 0.25 0.26
0.25 0.25 0.25 0.25
0.23 0.23 0.24 0.23 0.23 0.23 0.23 0.22 0.22 0.22 01-May
06-Oct
0.2
Nov-15
16-20
>20
0.15

0.11 0.11 0.11 0.11 0.11 0.11 0.11

0.11 0.11 0.1
0.1
0.08 0.08
0.07 0.07 0.07
0.06 0.07 0.06 0.06 0.07
0.05

0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
DISCUSSION

EFS has been reported in patients undergoing COH for ART. It was noted that some

patients with EFS had a history of poor response to ovarian stimulation, implying that ovarian

dysfunction could play a role72. Our findings suggest that most cases of EFS are observed in

patients with a diminished ovarian reserve. Low levels of AMH indicates decreased ovarian

function and/or low ovarian reserve. In our study a high incidence of EFS could be explained

by the patient’s cohort which consists women, whose age was older than 35 years. This
73,74
observation has been supported by previous reports associating EFS to female age . One

of the possible solutions to avoid EFS is applying a different COH regimen and/or triggering

of ovulation, by an enhanced dose of hCG in the subsequent cycle, as proposed previously by

Reichman et al.72.

In the growing follicle, the presence of an oocyte is obligatory and a situation of genuine

EFS can’t exist. Cooperation between the oocyte and follicular cells in the growing follicle is

extremely important. Cumulus cells coordinate oocyte development and maturation, provide

energy substrate for oocyte meiosis resumption, regulate oocyte transcription, and promote

nuclear and cytoplasmic maturation of the oocyte 77-81.

Different ovarian factors originating from oocyte and/or follicular cells are involved in

firm oocyte-follicle interaction and development. For example, deletion of Pdk1 in mouse

oocytes damages the survival of primordial follicles82 . Deletion of Pten in oocytes leads to

enhanced activation of primordial follicles, indicating that an intra-oocyte PI3K pathway is

needed for follicular activation83 .Communication between oocyte and surrounding follicular

cells could be reached via gap junctions of connexin (C×43), which is under the control of
LH. Interruption in this communication could prevent maturation of the oocyte. This action

of C×43 could play an important role in female fertility84.

Oocyte-cumulus cells cross-talk is extremely important for the follicle, as well as oocyte

development and competence. For this reason, unsuccessful oocyte aspiration is not evidence

for the real empty follicle. Our results revealed that successful oocyte aspiration in such cases

may be achieved by recruiting a different COH regimen and augmentation of the rec-LH

dosage. The failure of hCG to induce follicular maturation leading to EFS is an uncommon

complication of IVF treatment that in turn leads to a failure to collect oocytes in IVF cycles.

A low bioavailability of administered u-hCG is perhaps the most common and most well-

documented cause of EFS. In addition, low bioavailability maybe linked to intrinsic defects

in the in-vivo biological activity of some batches of commercially available u-hCG73.

The incidence of occurrence of EFS in successive cycles is not known, especially in a patient

with a history of spontaneous pregnancies. It has been suggested that some patients may need

a longer exposure to hCG in order for their cumulus±oocyte complex (COC) to detach from

the follicular wall and especially in those patients where GnRH agonist and gonadotrophin

are used in combination. Indeed, oocytes could be recovered when retrievals were repeated

24 h after the 1st failed recovery in the presence of both normal serum hCG and

progesterone78. Nonetheless, the repeated failure despite a 24-h delay and further dose of u-

hCG in the presence of luteinization suggested a problem which was specific to COC

detachment. As patient had conceived previously, spontaneous ovulation must have occurred,

thereby excluding the presence of an intrinsic defect in the LH receptor or ovulation.

Despite reports of successful oocyte retrieval using rec-hCG, there is a lack of theoretical

rationale to explain how this approach would work differently with the already proven

bioavailability of u-hCG administered. The utilization of endogenous ovulatory

gonadotrophin surges using either a natural cycle IVF or a stimulatory cycle that allows for a

natural LH surge, was seen as a more logical approach. Triggering an endogenous

gonadotrophin surge has become a possibility with the introduction of the antagonist regime

into IVF programs.

GnRH antagonists provide an immediate, but reversible, inhibition of a premature LH surge.

The inhibitory effect on gonadotrophin release can be competitively overridden by exogenous

administration of either GnRH or a GnRH agonist. The substitution of u-hCG administration

by a single dose of GnRH agonist for triggering ovulation has been used successfully in IVF

cycles for patients at high risk of developing ovarian hyperstimulation syndrome80.

This systematic review shows that most of the reported cases of EFS were actually avoidable

and did not represent any potential pathology in the relevant patients and that the risk of

GEFS is much smaller than was once thought. In fact, it can be reasonably argued whether

such a syndrome really exists. Many of the case reports may represent premature ovulation

that was not recognized at the time, which renders the incidence of the condition even rarer

than previously estimated. Therefore, the whole concept of EFS may simply reflect a rare

chance finding in any apparently normal cycle. There is, therefore, a definite value in making

a distinction between GEFS and FEFS for both management and academic reasons.

Furthermore, we believe that there is no merit in reporting FEFS because it does not further

increase our understanding of the condition and that a register of all GEFS should be

established if we are to identify potential risk or etiological factors. Moreover, essential data

relating to patients’ demography, stimulation protocol and hormonal levels, ovarian reserve,

and b-hCG level on oocyte retrieval day should be included in any future reports to extend

the benefit beyond the case report. The average age of the reported patients with GEFS was

33 years, and most patients had normal ovarian reserve, which refuses the hypothesis of

ovarian aging as a potential cause of the condition. It would be interesting to know the long-
term outcome of these patients, which would shed more light on the etiology. Patients with

GEFS, 83% had primary infertility, and all had normal levels of b-hCG 36 hours after

administration.

The present studies suggests that oocyte maturation and ovulation are time-dependent

processes, and that different patients require different lengths/intervals of time for treatment.

Therefore, we speculate that some patients may take longer to complete cumulus expansion

and ovulation, which would be crucial to oocyte retrieval. This indicates that the borderline

form of EFS or EFS in general may be treatable, and provides a new treatment option for

such patients in the future, which is promising for both patients and physicians. The etiology

remains unclear and some have even cast doubt regarding the existence of the syndrome. EFS

has been classified into ‘genuine’ and ‘false’ types. In a review of EFS by Stevenson and

Lashen , 33% of EFS cases were labeled as genuine and 67% as false type. Occurrence of

EFS is a rare but frustrating complication of IVF, leading to cycle cancellation. It may cause

substantial stress and anxiety for both patients and physicians during ART.

Patients with EFS present a challenge to the treating physician. No single treatment is

effective. Some authors, relying on the low frequency of recurrence, recommend repeating

the standard ART cycle, regardless of the treatment protocol 81. Since in most EFS cases,

down-regulation was achieved by GnRH agonist (possibly presenting the higher prevalence

of agonist over antagonist in ART cycles), shifting from an agonist to antagonist protocol was

suggested 82. In cases where no oocytes are aspirated from one ovary and hCG levels are low,

some have suggested readministering hCG from a different batch and aspirating the second

ovary. Others suggested changing the hCG from a urinary to a recombinant preparation.

Hourvitz et al. (2010) presented two women with EFS who were successfully treated with in

vitro maturation. The two treatment remedies that were used in the case presented here, and
thus discussed thoroughly, are using GnRH agonist for final oocyte maturation (Lok et al.,

2003) and prolonging the interval between ovulation triggering and OPU (Uygur et al., 2003).

In this review, we thoroughly searched the literature to identify several studies and case

reports regarding EFS published to date in PubMed to verify the reality of EFS. The term

used for the search was ‘empty follicle syndrome’. The references of the articles found in the

search were also explored. The papers included were observational studies, scientific reviews,

case reports or case series, and letters or comments. The studies that have been published in

English were included. The papers have been reviewed and presented in order of their

importance or the date of the studies.