Empty Follicle Syndrome

Question:
Sorry for the long question but I wanted to make sure you had a good picture.....
I am 38 year old and have been trying to get pregnant for a while. I got pregnant using clomid and HCH shot but had a pregnancy lost in 2007 at approx 24 weeks. I did a thrombophilia work up and one of my clotting factors was borderline so the action that I was to go on blood thinners with a next pregnancy. High FSH has been a problem as it peaked at 20.23 during one cycle when I was doing the IUIs. I had to date 3 unsuccessful IUIs and two cancelled IVF due to empty follicles. The first IVF cycle I had two follicles after using Lupron in the beginning and then repronex and gonal F for several days and finished with Novarel HCG shot.
　　
The second attempt my RE did a different approach. I was placed on birth control for one cycle and the next cycle I start with clomid and then repronex and gonal followed by ganirelix and the last norvarel shot before retrieval. Note that my FSH was 8.8 but estradiol was high at about 90 so that made my FSH skewed. I had four follicles (the most I had have) and they were all empty. I was concerned that the shot was given properly but my RE said that does not have anything to do with them being empty. After the miscarriage I was always taking baby aspirin but no heparin.
　
Mentally I am not ready for donor eggs and my husband has flat out said no. I want to exhaust all options before I give up. As you would say, "pull out the full court press". I want to try one more cycle but I have doubts whether I should try again with this RE or try someone else. Can you shed some light on the empty follicle syndrome and if I have a chance? I am so desperate that I am trying acupuncture and herbs while I am on "ovary rest" break.
　
Answer:
Hello Patrice from the U.S.,
　
"Empty follicle" syndrome is a description/name of a condition that is found when no eggs are retrieved from obviously adequate sized follicles. It can occur at any age, but seems to be more prevalent the older one gets. So, a woman in her 40's could still have regular menstrual cycles and ovulation, but no egg will be ovulated so pregnancy does not occur. With IVF, we find this when we go to retrieve and get no eggs back. It is thought that this is the "normal natural condition" in the aging ovary. A woman essentially runs out of eggs. However, that does not seem to be the case in younger woman, since younger women stil have a full complement of eggs. So, "running out of eggs" does not seem to be the whole answer.
　
I have had several cases of empty follicles in both younger and older women. In the younger patients, I have concluded that they did not get adequate HCG stimulation. Previously I had used a generic HCG and worried that it was not produced properly or suffered some type of inactivation in shipping or storage. I therefore switched to Ovidrel. Since then, the incidence of empty follicles has been resolved except in a couple of exceptions. I had two moderately obese young woman have a very poor retrieval despite lots of follicles (both were PCOD patients). By poor retrieval, I mean that there were either no eggs or we only retrieved 1 or 2 eggs despite 25+ follicles. They had given the Ovidrel as instructed, into there belly. In the subsequent cycle, I had then give it in the back of the arm where there was some fatty tissue but much less than the abdomen. They then had good retrievals. This lead me to suspect that HCG stimulation was the problem, and that the increased fatty layer of the abdomen did not allow adequate absorption of the HCG, therefore the eggs did not release to be retrieved.
　
In your case, with an elevated FSH level, your age and poor ovarian stimulation, the problem may actually be a lack of eggs. However, you did not mention your weight so you might want to look at that possibility. In addition, you may not be stimulating well if you are not getting a large enough dosage of medication. For example, I use a total of 600IU of gonadotropins in the combination 450IU of Follistim and 150IU of Menopur. Are you using that much? If you are, then the poor stimulation is because of ovarian resistance as manifest by an elevated FSH level.
　
You certainly have the option of continuing to try with your own eggs if that is your only choice (per your husband) and you can afford continuing to try, AND you doctor agrees to allow you to keep trying. However, based on the cycles you have had, realistically Donor eggs is your best option, and the most cost effective since you would probably get pregnant quickly. Using your own eggs is a long shot.
　
If you don't think that your doctor is giving you an adequate chance, or being aggressive enough, then you certainly can consider changing doctors. The Doctor-Patient relationship is based on TRUST. If you don't have that trust, then you need to move on. If you trust your doctor's abilities then stick it out, albeit, every clinic and doctor have different protocols and treatments for difficult cases so that must be a consideration as well.
　
　
If you were my patient, as I mentioned, I would have you on 450IU follistim/150IU Menopur from the start, Aspirin 81mg per day from the start, Medrol 16mg per day from the start, Heparin 2000U twice per day from the start, Estrogen patches and progesterone from retrieval on and I use Ganerelix once the follicles reach 16 mms, NOT Lupron which will inhibit the ovaries from the start (called the long protocol).

I hope this gives you some information to think about.
　
Sincerely,
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com