Empty follicle syndrome in the setting of dramatic weight loss after bariatric surgery: case report and review of available literature

Objective: To describe empty follicle syndrome, potentially due to route of human chorionic gonadotropin (hCG) administration, in a patient who had previously undergone bariatric surgery. Design: Case report and review of literature. Setting: Academic medical center. Patient(s): A 42-year-old nulliparous, morbidly obese woman who had presented for assisted reproduction treatment after having lost 175 pounds via gastric bypass surgery, resulting in abdominal skin redundancy. Intervention(s): The patient's gastric bypass surgery had resulted in abdominal skin redundancy. In her first cycle, recombinant hCG was used with a luteal gonadotropin-releasing hormone (GnRH) agonist/recombinant follicle-stimulation hormone (FSH) protocol. At hCG administration, her estradiol level was 2342 pg/mL, and 18 follicles were measured. At retrieval, no oocytes were recovered, and her serum hCG level was 19 mIU/mL. In the subsequent cycle, identical ovarian stimulation was performed, with peak estradiol of 2891 pg/mL, but intramuscular hCG was administered. At retrieval, her serum hCG level was 45 mIU/mL, and 19 oocytes were recovered, resulting in 10 embryos. Five embryos were transferred, and a singleton pregnancy resulted. Main Outcome Measure(s): Recovery of oocytes. Result(s): Clinical pregnancy. Conclusion(s): Abdominal skin redundancy after bariatric surgery may alter the absorption of subcutaneously administered infertility medications. Additional studies are needed to treat infertile patients optimally after weight-reduction surgery.