Friday, June 17, 2011

Why wasn't the doctor able to collect any eggs ?

At the end of the egg collection, the first question every patient wants to know is - How many eggs did you collect, doctor ?

Egg retrieval is usually a very straightforward procedure, and we usually get at least one egg from each mature follicle ( more than 18 mm in size) . This is why we expect to collect at least as many eggs as there are mature follicles . However, sometimes, much to the doctor's chagrin and the patient's dismay, sometimes we do not get any eggs at all. This is not common, but let's examine why this happens , and what we can do about it.

Technically, if we do not collect any eggs at all , this condition is called " empty follicle syndrome
( EFS) ". Sadly, this term is abused and misused by many IVF doctors, who are happy to make this "diagnosis" and blame this condition when they are not able to collect any eggs from the patient.

In reality , empty follicle syndrome is a very specific condition, which refers to an iatrogenic complication, when we do not recover any eggs from the follicles because the patient has not been given her HCG injection ( the " trigger " shot) properly. This can happen because of many reasons ( some of which we can pinpoint only in hindsight !)

1. The HCG was not given properly
2. The patient did not take the HCG at the right time

Often the HCG is given late at night , and errors are commoner at this time. Thus, the nurse may forget to dissolve the active powder in the solvent, as a result of which the patient gets a shot of only sterile water ( and no HCG at all !). This kind of mistake happens far more commonly than you would assume - which is why it helps to be obsessive !

We insist that patients retain their HCG vials so they can show these to us before the egg collection ( allowing us to verify that the injection was given properly). In other cases, patients have confused am with pm, and taken the shot 12 hours ( and even 24 hours !) after they were supposed to !

Some clinics even routinely measure the blood HCG level prior to egg collection, to document that the HCG was administered properly.

How is EFS diagnosed and managed ? First, the doctor needs to think of it - and this diagnosis is usually thought of only after the egg collection has started ! If the embryologist has not been able to identify even one egg in the follicular fluid after Dr Anjali has flushed 3 mature follicles, we stop the procedure and re-assess. The first step is to do a urine pregnancy test ( which checks for the presence of HCG in the urine) - and we can do this on a urine sample obtained by catherisation of the bladder. If this is positive, this confirms that the HCG was given properly and empty follicle syndrome can then be confidently ruled out . We then reposition the patient, and continue with the procedure, and will often get eggs with more aggressive flushing.

However, if the urine pregnancy test during the egg collection is negative, this suggests that we are dealing with EFS. We stop the procedure; draw a blood test for HCG ( to confirm the diagnosis); give the patient a shot of 10000 IU HCG IM ; and reschedule the egg collection after 36 hours.We will then get eggs from the follicles at this time, thus "treating " the EFS effectively !

However, there are other reasons for not getting eggs from follicles, and these are unfortunately all too common in small, poorly run IVF clinics.

1. The follicles may have ruptured prior to the start of the egg collection. This can be diagnosed by the ultrasound scan, which shows that the follicles are no longer intact and there is fluid in the pouch of Douglas behind the uterus . This is uncommon, but can happen when clinics "batch" patients and do lots of egg collections on one day, when they are running late.

2. Sometimes, the doctor may have a technical problem during the egg collection. This is true if the doctor is not experienced; or if the patient is very obese; or if the ovaries are adherent to the pelvic side wall because of adhesions; and if the doctor does not take the time and effort to flush the follicles . This is more of a problem when the egg collection is not done under general anesthesia. In these cases, the procedure may cause so much pain to the patient that the doctor may be forced to abandon the egg collection, giving the excuse that " the ovaries were not accessible".

3. In older women with very few follicles ( and low estradiol levels), we may not get any eggs from the follicles , simply because even though the follicles look good on the ultrasound scan , they may not contain any eggs at all. This is seen in women with low AMH levels and poor antral follicle counts.

The best way to prevent these problems is to ensure you select an experienced IVF clinic ( which does at least 300 IVF cycle per surgeon every year). In patients with few follicles, it's best to do the procedure under general anesthesia, with double-lumen egg collection needles which can be used to flush the follicles ( to ensure that the doctor can retrieve even small immature eggs which are tightly stuck to the wall of the follicle).

It's important to remember that when the doctor does not collect as many eggs as is expected, it's not usually because of a biological problem with the woman, but rather a technical problem during the egg collection.

Unfortunately, doctors are not very forthcoming and forthright when this happens, and it's often hard for patients to find out what went wrong. However, armed with the right information, they are better equipped to decide what to do differently the next time !

Options include: better monitoring of the superovulation, with more aggressive superovulation and checking the estradiol level before timing the HCG; changing the IVF clinic; and using donor eggs ( this is useful only for women with poor ovarian reserve). Most other women with empty follicle syndrome have a good chance of getting pregnant with their own eggs , if the IVF treatment is monitored properly the next time around.

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