QuestionI was wondering if you could help me? I am 30 yrs old and been trying for a baby for almost 5 years with 2 failed IVF's. I have severe PCOS and secondary Amenhorrea. My LH/FSH have come back in line for my age and low, my AMH (very high 153, but in-line with PCOS) results have come back in line with my age also, and my SHBG are very high. I have also had Ovarian Drilling, but still nothing has seemed to kick-start my cycle.
I started my first IVF cycle in March and started on Gonal F 112.5 IUI and then Orgalutron (Progynova taken as my lining doesn't thicken) where it was all going to plan - I had 25 follicles. Had my Ostradial levels taken and they were very high 32,000, so I had to cost for 3 days - levels dropped significantly, but in that time I had a bleed and started to become very bloated and out of breath. Took Ovidrel trigger ready for egg collection. Egg collection day came where they went into 10 follicles to find them empty. They gave me another Ovidrel injection as they thought the first one could have been a dodgy batch, again my LH levels never increased, so was given a third injection (Bruserelin). Again, LH didn't increase, but decided to give egg collection another go where there found no eggs in the remaining follicles. I then ended up in hospital for 9 days with severe OHSS where I have 11 litres of fluid drained from my chest. The second cycle was in August where they were very cautious and started me again on Gonal F but 75IUI. It took a while to get started, but then after day 8 follicles started to appear. I was on Gonal F for 21 days, as well as Orgalutron, but by day 21 my Ostradial levels droped to 823 (13 follicles) so the cycle was going to be abandoned. We increased Gonal F to 112.5 IUI to see if Ostradial levels would increase, which they did (1324), so we went through with egg collection after taking Bruserlin to trigger. Again, all eggs where empty except a few cells and fluid. No-one at the clinic is able to explain to me why this is happening, If I am ever going to have a normal cycle or positive one, and even expressed that they think I could have the follicles, the cells, but not the eggs? I was wondering if you had heard of this and if you could shed some light on my problems? I look forward to hearing from you and thank you for taking the time to read my e-mail.
AnswerDear Suzanne from the U.K.
I have to admit that I have not heard of a person having "empty follicles" twice. The cause of empty follicle syndrome is unknown but it is suspected that there was inadequate HCG stimulation that prevented the eggs from maturing and releasing from the wall. That is what I suspect is the most common reason. With PCOS, despite the high number of follicles, most of these will be small and the eggs will fail to mature. However, there still should have been some maturation. In both your cycles, the stimulation process was skewed, so that may have contributed to the problem. My skewed I mean that they did not proceed in a straight forward fashion because of the development of OHSS in the first cycle and the estradiol drop in the second.
You are certainly a difficult patient to manage because of the sensitivity of your ovaries to FSH. I am very sorry to hear that you developed OHSS, but that was probably a consequence of the multiple HCG injections and the high estradiol level. You are what I personally call a "volatile" PCOS patient because your ovaries show resistance to lower doses of stim, then all of a sudden over-stimulate at higher doses. Such patients are difficult to manage.
I don't think that you are without eggs at your age. You just need to be stimulated/managed appropriately. Now that you have two cycles to learn from, hopefully the third will be successful. You have to keep trying. The buserelin trigger was appropriate for the trigger in the second cycle, but it is possible that he dosage was inadequate. I personally prefer Lupron 0.5 mg to trigger. You might want to suggest that to your docs.
Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf
