Tuesday, November 20, 2007

no such thing as empty follicles

I posted on www.haveababy.com (SIRMs forums where a doctor will respond to your posts for free) and here is what Dr. Sher said about empty follicles.

btw SIRM is a very reputable clinic and one of the top clinics in the US (from what I've been told)

It's nice to actually get an answer for once and not the crap my RE feeds me. I'll be interested to see what my RE has to say about it when I call him next week.

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Underdeveloped and mal-developed (dysmorphic) eggs often have an exceptionally dense surrounding cumulus cell cluster that tends to attach them tightly to the inner wall of the follicle. The hCG shot, which is intended to mature the egg and disperse(loosen) the cumulus cells so that the eggs will comes free upon suction and can thus be readily retrieved upon needle aspiration, often fails to cause sufficient dispersion of cumulus cells when the eggs are underdeveloped or dysmorphic. Consequently, such eggs are often so more tightly adherent to the inner follicle wall that they fail to release easily. In such cases the eggs may not be readily captured with the first attempt at follicle aspiration, requiring that such follicles be repeatedly irrigated( flushed) and or scraped to try and dislodge them. In severe cases, these fail to come free. When this happens there is a tendency to describe such follicles as being “empty” . Since this implies that such follicles did not house eggs, it is a complete misnomer. There is no such thing as “empty follicles”.

Since most RE's can easily perform the technical aspects of ER and since better quality eggs tend to readily release with the initial attempt at aspirating the follicle it follows that failure to successfully aspirate an egg is often due to the egg being immature or dysmature. The latter is usually indicative of the egg having an abnormal numerical chromosomal make-up (aneuploid).“Poor embryo quality is virtually synonymous with embryo aneuploidy and in >90% of such cases this is due to egg ( rather than sperm) aneuploidy.

Imperfection is part of the human condition. Thus a percentage of human eggs (regardless of age) will always develop abnormally (dysmorphism). Once exposed to an LH-surge or the “hCG-trigger" such eggs will have an abnormal number of chromosomes.

Egg dysmorphism and thus egg/embryo aneuploidy increases with age. In younger women ( <35yrs) 45%-50% of all eggs are aneuploidic, at 40yrs the incidence is about 60% at 43, approximately 80% and about 90% at age 45yrs. Fortunately, aneuploidic eggs/embryos fail to implant or miscarry early on in pregnancy. Sadly, depending upon which chromosome(s) is/are involved, developmental defects such as Down's syndrome (Trisomy 21) sometimes occurs.

The unavoidable threshold risk of age-related egg dysmorphism and aneuploidy can however be seriously compounded through over-exposure of developing eggs to male hormones (predominantly-testosterone). These hormones are normally produced by the connective tissue (stroma) that surrounds the egg-bearing follicle(s). Overgrowth of the stroma occurs with advancing age (beyond 35years) and/or at any stage when ovarian reserve declines below a certain threshold (evidenced by poor response to fertility drugs, rising day 3 FSH level, falling Inhibin B levels, etc.). The eggs of such women are thus inordinately vulnerable to an over-exposure to LH-induced ovarian testosterone. In such cases, over-administration of LH-like products(hCG) or LH-containing fertility drugs (Repronex or the use of ovarian stimulation protocols such as "Flare-agonist protocols" that establish very high LH levels early on in the stimulation cycle) can be especially harmful.


There is little one can do to reduce the age-related risk of egg/embryo aneuploidy. However since the risk of compounding egg dysmorphism and thus egg/embryo aneuploidy can be avoided by individualized stimulation protocol selection and precise timing of the hCG “trigger shot”… both very important considerations when attempting to improve egg/embryo quality and IVF outcome, especially in older women and those with diminished ovarian reserve.

Dr. Sher

19 comments:

Jennifer said...

Amy - It's great that you got some information from Sher - I've heard him and his practice is one of the best!

So, is Dr. Sher saying your RE didn't aspirate your follicles properly? His response was so long, I had trouble understanding exactly what he was saying.

M said...

It will be interesting to hear what your doctor says in comparison to Dr.Sher. I liked Dr.Sher's thourough explanation. I think sometimes doctors think we want the short, dumbed-down answer. Not true. I think most of us want the full, true answers. You have to wait til next week to talk to your doctor?

I don't know about you, but time is at a stand-still for me. This 2ww stinks.

Anonymous said...

empty follicle udpate

i wanted to post an update about empty follicles. last year, on my first ivf attempt, i was told after the retrieval that i had "empty follicles." my doctor
said he had never seen this before and he had no other thoughts about why this may have occured and that perhaps i had a condition where i would always yield "empty follicles". my husband and i were devastated. we did as much research as we possibly could and as you probably know, there's not a lot out there. we especially wondered what the fertility outcomes were of people who had "empty follicles." we ended up doing another two rounds of ivf and even though the retrieved follicle count was low (5 follicles), the follicles were not empty! i gave birth to a healthy, 8pound-6oz baby in august. I'm still not sure why my follicles were empty in the first attempt but i went on to have a healthy baby. there is hope after empty follicles!

Anonymous said...

Dear Anonymous, thank you for posting your story, I recently had a failed IVF attempt (two weeks ago). Days before the IVF the doctors counted 16follicles but they were only able to retreive four. The doctor was shocked given that I am only 28. They transferred 3 but I did not become pregnant. After hearing your story, I think there is still hope for me!!! Thank you

Maura Walker said...

Hi. My name is Maura. I am 25. I just had my first egg retrieval today. In brief I have severe and reoccuring endometriosis and am left with only one ovary with two large growths on it. Anyways I only had about 10 follicles 5 being large. I too had "empty follicles". I am heartbroken. My husband and I have paid out of pocket and are not sure if we can afford this process again. My doctor seems to think it was something with HCG shot for he told me to bring the empty vile with me to see him on Monday and not to worry about this...not sure what that means....heartbroken and frustrated....

Anonymous said...

Thanks for this posting. I had my retrieval this morning. I had 5 follicles on Friday, but they told me I only had 4 follicles today(Sunday) and they only got 2 eggs, the others were empty. I've got tons of questions- why would my body make empty follicles? Is this normal? DO I lack sufficient eggs to have 1 per follicle? I'm calling the RE office with my list of questions tomorrow. Thanks for having some info on this subject!

Anonymous said...

Well,this is my 4th IVF.My 1,2 and 3rd Ivf I had 10-15 follicles each time but only 2 eggs each time. My 4th one I had 14 follies 14mm-16mm and only got one egg.I just don't get it.I really think it was the trigger shot.Each time we used Ovidrel 250mc.I'm 35 yers old with FSH 8.1, e 10 -15 and no endo.What is going on with empty follies?

Jim + Mimi said...

Hi - My partner and I just had our first IVF cycle using a donor. As with most others commenting, she evidently had 15-17 follicles and only one viable egg came from it, 4 total but one did not survive ICSI, one was immature, and one showed defective chromosomes, we were told the rest of the follicles were empty. The donor has refused to let us see the stim sheets so we are in the dark regarding the protocol or how she stimulated but have a meeting with our Doctor Tuesday and would greatly appreciate any help suggesting questions we should ask. There was only one viable egg and it did not implant.

Anonymous said...

I just had my retrival this morning and was devastated to learn that there were no eggs after the painful retrival. There were 3 follicles but all were empty..I am now relieved after reading Dr Sher's explanation on "empty follicles", so there is still hope for me...

jenicini said...

So what do you do after you have something like this? Do you change to a different protocol?

Amy said...

Unfortunately there wasn't much I could do, it meant my egg quality wasn't much to be desired (bad egg quality) but yes changing a protocol may be best, I tried that, I ended up taking a break after 6 IVF's, had a doctor screw up BIG time then lost my insurance right before I was going to cycle with SIRM and do EEP protocol (estrogen priming)

Anonymous said...

I had my 3rd failed IVF attempt last month. Between 5-6 follies each time, but all empty. The last attempt was with the estrogen priming protocol. Got my best response in terms of follicles (6), but still empty. My RE also shares Dr. Sher's view that there's no such thing as empty follicles. He thinks the hCG may be the problem. Apparently there are a few cases where people react badly to it. I'm trying for the last time next month again using the estrogen priming, but this time with buserelin as the trigger. Good luck to everyone. This is a hard journey.

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Sorry for offtopic

Jasmine said...

It was such as good site to learn about there are people out there with "empty follicles". I had my egg retrieval yesterday and I got a called from the nurse that out of my 12-14 follicles, I only got 3egges, out of the 3 eggs, one were immature, two were still in the "unknown" stage. I am only 30 years old, all ultrasound came positive and all follices (the 12-14 of them) were grow in the size of 16-18 mm. I am so sad. My hope is that at lease one could work tomorrow so I can still have a chance to do the transfer on Day 3. Please pray for me.

indian said...

hi...evryone!!i had 2 failed ivf.at my first ivf,from 15-16 well sized follicles ,i got only 3 embryos out of which only one was in good quality,but did nt wrkd.second time with diffrnt protocol got 17-18 follies,but all were empty,we were shocked by hearing this..nw we r totally disappointed,blood karyotyping did,bt no prblm in it.nw i find some hope frm an anonymous's story..tanx...

Anonymous said...

Hi, just had my second retrieval. I'm 32 with severe endo, resected last December. At my first cycle, I had 5 great follicles between 18-24mm, using 225u of Gonal and only got one egg. It fertilised, but was slow dividing, had a day 3 transfer and there was no pregnancy. At retrieval today, I had 9 follicles after changing to Puregon at 300iu, they were between 8-25mm with 6 follicles between 14-21mm. Again, I only got one follicle. We're waiting to see if it fertilises, buy my Dr is going to refer me onto someone else who specilised in the more difficult cases. Fingers crossed

Anonymous said...

just had my forst cycle of IVF, I am devastated....I had no eggs inmy follicles, even though I had 5 follicles and all of them were of goodsize, came out of retrival and was struck with bad news..have been crying since then. I am 33 yrs old, adn the doctir thinks that i need to repeat my IVF cycle, as i have normal cycles, and no endo...have read the posts..thanks so much..it definately gives me hope.

CS said...

Thanks, this is good info! I have an IUI scheduled for tomorrow, 2 follicles, but RE says I only have one egg based on my estrogen level (~1000)

Amy said...

CS-with an e2 of 1000 you can very easily have more then 1 egg. Weird that he thinks you only have one. Each egg puts out any where from 200-600 estrogen I believe