Two triggers, no oocytes: a rare case of genuine empty follicle syndrome overcome by dual trigger protocol

Empty follicle syndrome (EFS) is an uncommon but frus­tra­ting phenomenon observed during assisted reproductive tech­no­logy (ART), wherein no oocytes are retrieved de­spite op­ti­mal ovarian response and adequate follicular ma­tu­ra­tion. It can be classified as genuine or false, based on the serum β-hCG levels at the time of oocyte retrieval. We pre­sent a rare case of genuine EFS in a 28-year-old woman with polycystic ovary syndrome (PCOS), undergoing her first in vitro fertilization (IVF) cycle using a GnRH an­ta­go­nist protocol. Despite optimal follicular growth and an ap­pa­rently timely recombinant hCG (r-hCG) trigger, no oocytes were retrieved, and serum β-hCG levels confirmed adequate drug administration. A rescue hCG dose and repeat as­pi­ra­tion also failed to yield any oocytes. In the subsequent cycle, a dual trigger approach using GnRH agonist plus low-dose hCG led to successful retrieval of mature oocytes and em­bryo formation. This case highlights the diagnostic and the­ra­peu­tic challenges of genuine EFS and supports the use of dual trigger protocols in high-risk patients, particularly those with PCOS, to improve oocyte maturation and IVF out­comes.