Sunday, March 4, 2012

Young IVF Patient Fails Two IVF Cycles: Empty Follicles


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


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
Monterey, California, U.S.A.


  1. Hi I am 31 yrs old as well and just had my first ivf cycle. We have had an ectopic pregnancy 2 years ago and had my right tube removed. We haven't been able to conceive after. I have tried 6 months of femara prior to this without success. my right ovary seems dominant and the left responds poorly. My husbands sperm is fine. My ahm is lower than usual for my age at 1.9. I have been on 175 puregon for 12 days before triggered. I had 7 follicles 13,20,20,20,21,25,30 they expected the large follicle to be a cyst. Only two eggs were retrieved and none of these fertilised. My question is could i have been triggered too late?

    1. Hello June 29th Anonymous,

      Yes, it is possible that you were triggered too late. Did you use any medication to prevent ovulation such as Lupron or Ganerelix or Antagon? If not, then ovulation can occur once the follicle reaches 18-20 mms. I would be highly suspicious that this is what happened.

      Good Luck

  2. Hello Dr.Edward,
    I have gone though IVF in the month of July which was a failure.I did not get my periods this month.i started bleeding on the 4th of july after IVF which was my 8th day after IVF but my atucally date is 14th i did pergancy test on 23th aug which is negative what must be reason that i did not get my periods.

    1. If you were taking hormones, like progesterone, to support implantation and the early pregnancy then that would have prevented a period until they were stopped.

  3. Hi Dr. Edward,

    I'm PCOS and had my LMP on 6/10/2014 then take my first cycle of clomid. July 18,we found out that I was pregnant. Had 3 UTZ and was told that the baby is not growing as it should be. Was always advised to do repeat scan. My latest UTZ was last week with the following impression:

    Early intrauterine pregnancy.
    5 weeks and 1 day by sac diameter (1.09cm)
    yolk sac .79cm(megayolk sac) with subchorionic hemorrhage inferior pole .88ml.normal ovaries,corpus luteum-ryt.
    Note:with a suspicious echogenic like structure probably developing embryo .19cm. Lateral to the megayolk sac is another ring like structure could be another yolk sac .25cm.

    I dont want to keep my hopes up as I know that enlarged yolk sac is indicative of abnormal pregnancy, but why is there another yolk sac in normal size? can that help in giving me a positive outcome? I was advised to repeat the scan in 2weeks. now Im on Duphaston and duvadilan. At times, I have small brown spotting. Please advise. Thanks

  4. Hi I had a period july 28th was 4 weeks preg and miscarried August 28th I bled for about a week. I am now preg again first ultrasound 10/11 dated me at 5w2d when I should of been 6w2d they only saw yolk sac no fetal pole. Repeat ultrasound on 10/24 dated me 5w6d a yolk sac measuring 6.7 and a hb of 70? Now they are saying slow hb and enlarged ys and that they weren't sure if the hb was fetal or maternal although us tech stated that it was fetal to me. I have a repeat us Monday 10/31 should I be worried? Slow growth or hb I'm not sure when I ovulated. I still feel preg.but I'm feeling like they are trying to doom something that might have a chance. What is your opinion. Also the crl was .24cm on last ultrasound.

  5. Hi Doctor I need your opinion. I had my lmp on July28th got preg miscarried on August 28, 16 bled for a week and am pregnant now still. I've gone to 2 different ultrasounds first 10/11 measured 5w2d a week behind. Second ultrasound10/24 measuring 5w6d measuring 2-3 weeks behind. Was told hb was seen that was all. Later looked at us tech notes she said large yolk sac measuring 6.7 and slow fetal hb but then went on to say couldn't tell if hb was mine or fetal. I'm rescheduled for ultrasound Mon 10/31 should I be worried about another miscarriage?



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