Where Did My Eggs Go? Unpacking the Myth of Empty Follicle Syndrome

You've done the ultrasounds, the shots, the bloodwork — and then retrieval day comes, and... nothing. Zero eggs. What just happened?

In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols dives into one of the most confusing and emotionally crushing outcomes in IVF: Empty Follicle Syndrome (EFS). But before you panic, know this — most cases aren’t what they seem.

We’ll break down:

• The difference between true vs. false EFS
• Why true EFS is rarer than a unicorn eating tacos
• How trigger shot timing and hormone levels can lead to confusion
• What doctors actually mean when they say “empty follicle”
• Real strategies for preventing and managing this situation

Whether you've heard the term before or are just trying to understand your IVF journey better, this episode will give you clarity, peace of mind, and as always — a side of science and salsa.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

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Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:01

Today we talk about empty follicle Syndrome, also known as EFS. I'm Dr. Mark Amols, and this is Taco about Fertility Tuesday. Today we're diving into one of the most frustrating and, frankly, most misunderstood experiences in ivf. Empty Follicle syndrome, or some patients describe it. I had follicles, but no eggs. What the heck happened? You've done the shots, the ultrasounds, the blood work, and then you go on the retrieval. And crickets. It's like ordering tacos and getting an empty shell. No cheese, no salsa. Just a lot of disappointment. So today we're going to talk about what antif follicle syndrome actually is, why it happens, and why, in most cases, it is not what it seems. You'walk away from this episode understanding the science, and hopefully feeling a little less freaked out and a lot more informed. So what is empty follicle syndrome? Let's start with some of the basics. Empty follicle syndrome, again, also called efs, is when no eggs are retrieved during an IVF cycle, despite what looks like a very good response. In other words, your ultrasound showed growing follicles. Your estron levels look solid. Everything looked optimistic. But when the retrieval happened, no eggs, not a single one. So that's empty follicle syndrome. Well, here's the kicker. Not all empty follicle syndrome is created equal. There are actually two types. There's true empty follicle syndrome, and then there is false empty follicle syndrome. True empty follicle syndrome is when everything was done right. The trigger shot was taken correctly, the hormone levels were normal, and still no eggs. And this is actually quite rare. Like, we're talking unicorn rare. It'actually not uncommon for some doctors to never see this in their entire career. This type of error is not due to user error or lab issues. It's believed to be related to a biological or maybe a genetic issue with how the follicles develop or how the eggs separate from the follicle after being ovulated. Whereas with false efs, something went wrong with the trigger shot. Maybe it wasn't absorbed. Maybe it was taken too late. Maybe the instructions weren't clear. In these cases, the eggs were likely there. They just didn't mature or detach from the follle wall. So how rare is it really? Let me be super clear here. M true EFS is extremely rare. Again, many doctors will never see it in their entire career. We were talking tens of thousands of IVF cycles before one true case is seen. Even in the highest incidence, it's about one in 2,000 cycles. And that would be in the highest incidence in some studies. But most studies show it'extremely rare. You are more likely to be hit by lightning while eating tacos under the blue sky than the half EFS s happen. However, false EFS is more common. Still rare, but common. Somewhere between about 0.5 and 1% of IVF cycles. And even that number has dropped over time as cllingte have got better at preventing trigger related issues such as checking an HCG level after the trigger shot to make sure it worked. So if your retrieval didn't go well and you were told that maybe it's efs, it was more likely a hiccup in the process than a mysterious ovarian disorder. The term empty follicle syndrome was first coined back in 1986 and since then there's been some controversy about whether it's real or not. Matter fact, many doctors don't even believe it's real and believe it's just some fancy label for messing up. I myself fall into that group. I personally have never seen a case of empty follicle syndrome that I haven't figured out why we didn't get the eggs. But over time we start to recognize that while rare, true EFS does exist, even though I've never seen it. And likely it's due to some weird ovarian or genetic factor. And think get most of the time someone's told they have efs they probably don't. It's probably not true. Efs, they are technical issues and understanding that distinction is key to knowing what actually happened in your cycle and how to fix it. So how do we diagnose empty follicle syndrome? Well, let me tell you what really happens. Usually you're doing the retrieval and all of a sudden you're not getting follicles. And right away you start realizing something is not right. Now, even though you've verified Hg levels the day before, that's the first thing I go to check the EG levels. Now sometimes it might be a little bit lower and we said, well, it's still okay. And then you start to second guess it. But technically if it's above 30, it's not the ACG. The next thing you start to wonder is what if they started ovulating too soon and maybe they ovulated the eggs. And what we do is we check the progesterone level from the day when we drew the HCG and we check the progestne level on the day that they triggered. If we see the Progesterone levels already elevated or is higher than expected on the next day. We know that's a possibility that they ovulated too early. And that's why we're not seeing the eggs. now keep in mind, if there was only one follicle or two follicles, we also realized that maybe we just didn't get the egg. What's shocking the most, people, is we're not actually going in there and picking up the eggs. We're taking a needle, we're putting it into the follicle, and then we're pulling the fluid. And sometimes the suction of pulling up that fluid does not pull the egg. And that's where this empty follle syndrome gets a little murky. Because the egg does have to release from the follicle. And so if the egg is very immature, it may not release. And if there is some type of genetic issue that's causing the egg to not release, then it also won't release, leading to the same issue. One of the other things I do is I talk to my embryologist. I say, are you seeing cells? If they're seeing cumulus cells, then I know that they're being released, and I should be getting an egg. If they tell me there are no cumulus cells and it's not releasing those cells, then maybe that's why I'm not getting egg. Because they didn't absorb the HCG well, or there's something else going on. What's interesting is, is that sometimes I really don't know why, but what I can tell you is most of the time, I get all the achggs. And so when I don't, I know something is wrong. And sometimes the next day we figure it out, because then we see the patient has multiple GVs s. Or there's something else that shows up that helps us understand why we didn't get all the eggs. I wish I had an answer for you of what's going on in true empty follicle syndrome, but we're not really sure. And that's what's so frustrating. There are some theories, though. What if there'some type of genetic mutation in the LHACG receptor, Meaning yourollicles literally don't respond to the trigger shot. There's no way they can. The receptor is messed up. Or as we talked about, what if the eggs are detaching too early or degenerating before the retrieval? Like a balloon popping and so there's nothing to get? Or is it even possible that follult are Developing without actual eggs inside. Like ah, we're talking about tacos shells without any filling. There have been some studies showing that INS sisters, both of them had true empty falal syndrome and they had the same genetic mutation. So the point is it is real and it's probably biological in nature. But keep in mind this is a unicorn issue for most people. This is never going to happen. And that's not something you really need to be worried about. Now when I say you don't need to be worried, I'm saying worried about the true empty follicle syndrome. Now it comes to false empty follicle syndrome. Again that's 0.5 to 1%. That is something you could theoret encounter and hopefully your clin does things like checkacg levels after the trigger shot or LH levels that make sure it worked because I've have had had patients come in and their Hg levels were low the next day after the trigger shot and we found that, that they messed up. Now it's never their fault because you guys are not medical people. Matter of fact we're asking you guys to do a lot. We're telling you all of a sudden to learn how to give yourself shots and how to pull up medications. And so when that happens I actually take it personally responsible and feel like we didn't do a good job teaching. But the point is what caused the ACG not to be there is because it never went in their body. And that could happen, although it seems impossible, it can happen. Now the great thing about is if you catch that trigger issue, you can actually give a trigger then, and then do the retrieval two days later at 36 hours. That's how clins can prevent false EFS. Some clinics might even combine HCG and GRH, on older patients. That's actually one of the treatments. When you run into this situation where maybe you get fewer eggs than you expected, people will do a dual trigger. If we're worried about the person ovulating too soon, we can adjust the timing the retrieval. So instead of doing that 36 hours, we can do it at 35 to reduce the risk of early ovulation. The good news is most patients with false EFS can end up having a perectly perfect cycle after making adjustments. And surprisingly, even in two efs they usually have a successful retrieval of eggs, even with doing the same thing twice now. I can't imagine what your feelings must be if this happened, but getting no eggs seems to me be devastating. I mean that's not even on our radar that that would happen. And so that's why it's important for clinics to do these things, to make sure that the false EFS doesn't happen. But if it does happen, it's not your fault. If there is some type of genetic issue, you didn't cause it. And the more important thing to understand is it doesn't mean you don't have eggs. That's going to be the first thought you think. As I mentioned, most of the time it going be some type of technical or timing issue. And even if it is true efs, it doesn't mean it's going to keep happening. Usually if it happens, it happens one time and doesn't happen again. One of the biggest problems is doctors will use the term empty follicle syndrome a little too frequently. And that can make people think it happens more often when in reality it probably wasn't empty follicle syndrome. Such as let's say you have 12 follicles and only get eight eggs. That's not empty follicle syndrome. Let's say you have two follicles and they go to retrieve the ACHGGs and they don't get any. Again, that's not empty follical syndrome. Because if they're getting those cumulus cells, it just means they didn't get the egg. I personally feel that a lot of doctors use that as an excuse when they don't get EGs and they'll say things like, well, that follicle didn't have an egg in it, and that's not really real. Now it's true that the follicle may have not had a mature egg in it, and that's why they didn't get the egg in or they just didn't get the egg. And that's why I tell my patients, I say, listen, I really tried to get the eggs. Unfortunately I didn't. The egg could have been immature. And that's why I was talking about the next day. The next day. If you find out a lot of those eggs were immature, then I realized that's where the problem is. And now I maybe need to extend their stimulation out a few more days because it takes more time for their eggs to mature. This is where I'm always talking about how IVF is amazing because we can look back and we can look at the information and make adjustments. In closing, where did the eggs go? Well, in most cases they didn't disappear. They just didn't get the right signal to show up to the party. And the good news is we can usually fix that signal the following time. Empty Follicle Syndrome is real, but very rare. What's most common is a retrieval that didn't go perfect due to a fixable issue. And that means there'a path forward for you. Thanks for listening to this episode. We talk about Fertility Tuesday. If you liked this episode, as I always say, please give us a five star review on your favorite medium. Tell your friends about us, but most of all, keep coming back. And remember, an IVF throws you a curveball. Talkac about Fertility Tuesday's got the science, the strategy, and the side of salsa to get you through it. I look forward to talking to you again next week on Taco Bell. Fertility Tuesday.