Young IVF Patient Fails Two IVF Cycles: Empty Follicles

Question:

Dear Dr. Ramirez, I am 31 years old, have never been pregnant. My husband and I haver been trying to conceive for about 3 years, tried 5-6 cylces of Femara.

I had three failed IUI's and two failed IVF cycles. The first IVF cycle there was one egg but it disintergrated before it could fertilize. The second IVF cycle there were no eggs. Each cycle had 14-16 follicles 8-10 of them being mature. My AMH level is 2.19. My husband has been tested and is fine. I have a left blocked tube, which they say could be a spasm reaction from the dye. During the IVF I was on Bravelle, Menopur and Ganerelix injections, along with the trigger shot. It is emotionally and financially draining. Any thoughts? Thanks, H. from New York

Answer:

Hello H. from the U.S. (New York),

There is a finding called "empty follicle syndrome" where no eggs are within the follicles. But this occurs in a single cycle and those patients generally have eggs when retrieved in subsequent cycles. I have had young patients, and many older ones, with no eggs retrieved. In older patients, many of the follicles don't have eggs i.e. they have run out of eggs, so it is fairly common. But, this is not common in young women.

In most cases when eggs are not retrieved in a young woman, it is often because either (1) the HCG trigger was not adequate, or (2) the follicles sizes were not mature enough and therefore the eggs were not mature. I am suspicious that you fit into the latter category based on your first cycle. It is possible that you are being triggered too soon. In terms of the HCG not being adequate, when I previously encountered empty follicles in my young patients, I came to the conclusion that either the HCG had a manufacturing defect, was not stored properly or not given properly. I used to use generic HCG. I have now switched to the brand HCG, Ovidrel, and have not had a repeat of that problem.

I also worried that in more obese patients, the depth of the injection was not adequate to get the HCG into the tissues so I have my obese patients given the HCG injection into the back of there arm where the fatty tissue is less, rather in the abdomen where the fatty tissue is thicker.

Finally, if it is that the follicles were not allowed to grow sufficiently, that is a procedural problem. So you either can ask your doctor to wait a little longer to trigger you (I have found in my experience that I have to wait until the lead follicles are 21-22 mms rather than the 18 mms that most doctors will trigger at) or you can try a different clinic/center because each doctor and clinic are different and the outcome can be different.The bottom line is not to give up.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.