ZP1 mutations are associated with empty follicle syndrome: evidence for the existence of an intact oocyte and a zona pellucida in follicles up to the early antral stage. A case report

Hum Reprod. 2019 Nov 1;34(11):2201-2207. doi: 10.1093/humrep/dez174.


Empty follicle syndrome (EFS) is the complete failure to retrieve oocytes after ovarian stimulation. Although LHCGR and ZP3 were identified as causative genes, it is still unclear what happens to these patients' oocytes, and the pathogenesis of EFS remains obscure. Here, we identified six novel ZP1 mutations associated with EFS and female infertility that was inherited recessively in five unrelated families. Studies in CHO-K1 cells showed that these mutations resulted in either degradation or truncation of ZP1 protein. Immunohistochemistry using ovarian serial sections demonstrated that all preantral follicles had normal architecture, but with a thin ZP, lacking ZP1, surrounding the growing oocytes. The antral follicles were also defective in normal cumulus-oocyte complex organisation, leading us to speculate that the lack of ZP1 might lead to oocyte degeneration or increased fragility of the oocyte during follicular puncture, ultimately resulting in EFS. To our knowledge, this is the first study that presents morphological evidence showing normal preantral folliculogenesis with abnormal ZP assembly in EFS patients. Our data provides a better understanding of the biological functions of ZP1 in human ZP assembly and folliculogenesis and gives new insights into the pathogenesis of EFS and possible therapeutic developments.

Keywords: ZP1; causative gene; empty follicle syndrome; follicle development; zona pellucida.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Alleles
  • Exome
  • Female
  • Genotype
  • Humans
  • Infertility, Female
  • Oocytes / cytology*
  • Ovarian Diseases / genetics*
  • Ovarian Follicle / pathology*
  • Ovarian Reserve
  • Ovulation Induction
  • Sequence Analysis, DNA
  • Zona Pellucida / pathology*
  • Zona Pellucida Glycoproteins / genetics*


  • ZP1 protein, human
  • Zona Pellucida Glycoproteins