Before talking about the history of ovarian pick-up, it is important to have a look at the history of the medicine, especially to take into account the part concerning female reproductive system anatomy. The anatomical and physiological description of the ovary, the most important reproductive organ, takes place in a recent historical period with respect to other human organs. Before the fourteenth century, the ovary was considered as a female testis and the uterus as an empty penis.

In 1543, Andreas Vesalius (Fig. 1.1) published De Humani Corporis Fabrica; with its extensive account of the anatomy of the generative organs, he carefully and systematically introduced the structure of the human body in a way that was truthful to the findings of human dissection that had never been accomplished before [1, 2].

He noted the disposition of the Fallopian tubes but failed to clarify their specific function [3].

Instead, he considered their relationship with the ovaries was analogous to that of the male ducts with the testes, so he illustrated the ducts as coiled round the “female testes.”

In 1721, an Italian scientist, Antonio Vallisneri (1661–1730), with this expressive description: “Young peasant woman, married, moderately plump, infertile, with ovaries larger than normal, like doves’ eggs, lumpy, shiny and whitish,” (Fig. 1.2) described for the first time the clinical and pathological features of the “polycystic” or “micropolycystic” ovary [4].

He was a student of Marcello Malpighi (1628–1694), one of the first ovary researcher. Malpighi had made his first known drawing of a monkey ovary in 1666 and had noted the Graafian follicles.

He had reasoned that the actual egg is within the ovary. In contrast to the Graaf’s theories that the follicle was the egg, Malpighi proposed in 1681 that the egg was derived from the luteal tissue present in a mature mammalian ovary [5, 6] (Fig. 1.3).

Gabriele Fallopio (1523–1562) (Fig. 1.4), one of the greatest anatomists of the sixteenth century, had noticed the follicles previously but he didn’t recognize its reproductive significance [7]. Moreover, he was able to prove that the Fallopian tube is a unique organ that connects the uterine horn to the ovary [8] (Fig. 1.5).

It is noticeable to underline that the only approach in vivo to understand the female reproductive system was the manual abdominal examination [9, 10]. In fact, the most fundamental diagnostic instrument in the past was the hand.

Trotula de’ Ruggiero of the famous school of Salerno was the first female physician in the history of medicine and the first female professor of medicine [11]. She was one of the first physicians to describe a number of obstetrical and gynaecological conditions and also wrote on male infertility.

De passionibus mulierum was probably her most famous work, and she was included in the “famous quartet of Salerno” in the eleventh century by several medical historians [12] (Fig. 1.6). Trotula’s chapter on the causes of infertility is noteworthy as she recognizes both female and male infertility.

Trotula writes that some women “have a womb so soft and slippery that the seed having been received cannot be retained in it. Sometimes this happens through a defect of the male who has seed so thin that when it is poured into the vagina it slips out because of its own liquidness.” [13].

For many years, the gynaecological examination was the only way to evaluate ovarian conditions (Fig. 1.7).

Only with the discovery of ultrasound the evaluation of the anatomy of the ovaries and their function has taken a considerable step forward (Fig. 1.8).

Oocyte pick-up may be defined as the process of the aspiration of follicular fluid, and the oocytes contained therein, directly from the ovaries of a woman, before them being released spontaneously from the ovarian follicles.

Aside from the occasional warnings from Palmer and Klein [14] regarding the retrieval of human oocytes using laparoscopy for the cytological evaluation of their quality—it is only with advances in the technologies of assisted reproduction, that the need has been recognized for timed retrieval of initially mature oocytes (1969) via laparoscopy (and usually after the induction of multiple follicular growth). Although this possibility became popular with the famed collaboration between Patrick Steptoe and Robert Edwards in 1969, it is also important for us to remember that, in 1964, 5 years earlier, Steptoe had already presented recordings made with ANSCO film with pictures of laparoscopic retrieval of human oocytes [15], at the “First World Congress on Gynecological Coelioscopy” (Palermo, November 1964).

In 1971 the pioneering work of Steptoe and Edwards brought to the first embryonic transfer after laparoscopic pick-up with different types of ovarian stimulation. After 32 failures, the first pregnancy achieved in 1975 turned out to be ectopic [16, 17]. The first successful outcome of IVF was achieved on 27th July 1978 with the birth of Louise Brown in Manchester from a laparoscopic retrieval on the spontaneous cycle of a single ovarian follicle. In the years after that, following on from the excellent results achieved by Steptoe, oocyte pick-up was carried out using the laparoscopic technique, with hospitalization and general anaesthesia.

It is worth noting that, despite the introduction of abdominal transducers and vaginal scanners in the mid-1980s, which allowed for the echographic pick-up of oocytes, Patrick Steptoe was a proponent of laparoscopic retrieval until his death in 1988 and he staunchly defended its main advantages. These can be summarized as follows: (1) the possibility of carrying out a complete pelvic diagnostic exploration contemporaneous to oocyte retrieval; (2) A high percentage of oocyte retrieval; (3) the possibility of carrying out procedures on the fallopian tubes, such as salpingolysis and tubular disagglutination immediately after pick-up.

The laparoscopic technique utilized for oocyte pick-up does not differ greatly from the traditional method—aside from certain details that can be listed as: (1) no instruments are inserted into the uterine so as to avoid damage to the endometrium, which after few days must accommodate the developing embryo; (2) the patient may be positioned on the operating table with the lower limbs lying flat, as in most normal procedures; (3) particular attention must be placed when introducing the Veress needle and to the trocars for access since we are dealing with patients undergoing multiple operations; (4) the gas in pneumoperitoneum which is safe for the oocytes, such as a mix of 90% nitrogen, 5% oxygen, and 5% carbon dioxide, is used in oocyte culturing; (5) a choice of aspiration needles which takes into consideration the size of the cumulus oophorus, the adhesive nature of this structure, as well as the need to utilize the minimum space for the liquids and the maximum flow rate inside the system [18]. This flow must be continuous to minimize the liquid turbulence, so as to avoid oocyte adhesion and the damage caused during its transposition. Steptoe used a double-cannula needle (Figs. 1.9 and 1.10) and soon after nearly all groups active in Italy were using Craft double-cannula or the Renou single-cannula needles (Fig. 1.11), or different models (Figs. 1.12 and 1.13).

Follicle aspiration must be done using general aspiration systems but with intermediate reducers attached to them, or using a suitable aspirator with micro-regulation, such as that of Craft. Optimal pressure for the aspiration is between 60 and 100 mmHg (Figs. 1.14 and 1.15).

The procedure begins by puncturing the largest follicle in one of the two ovaries and penetrating them by about 5 mm (Fig. 1.16) [19].

The majority of the literature suggests an apical puncture of the follicle, whereas others (Cittadini) prefer to make the puncture towards the base since apical puncture takes place at the most eroded point, can, on occasion, mean a hole larger than the needle and the consequent leak of follicular fluid and the possible loss of the oocyte [20–22]. Furthermore, the technique involves a greater risk of leaving the oocyte behind in the follicle and then have to retrieve it via washing or flushing. The aspirator, controlled via a pedal, must be switched off prior to the penetration of the oocyte by the needle so that the increase of the intra-follicular pressure is rapidly decreased which is determined at the moment of entry and can cause the breakage of the follicle. As the aspiration takes places, the tension of the follicle gradually reduces thus it is opportune to create a hollow with the needle, in which the residual follicular liquid and eventual oocyte can be collected. Once the follicular liquid has been completely aspirated it is standard practice to clean the needle by aspirating in the middle of the collection, with the aim of preventing the formation of internal coagulations whilst removing the oocyte which may have remained attached to the walls. Employing this technique, Cittadini has a retrieval percentage of 90–95% without the need for flushing, whilst the Australian groups obtain this percentage only after the fourth or fifth flushing. Many authors prefer an oblique vision telescope (30°) for an easier vision of the ovarian walls (Figs. 1.17 and 1.18).

The aspiration is interrupted when a small opaque mass is visible as it could contain the oocyte and cumulus oophorus. The needle is kept on site until the laboratory provides a response.

Normally, only follicles with a diameter superior to 15 mm are punctured for two main reasons: firstly because follicles with a diameter inferior to 15 mm generally do not contain mature oocytes and secondly due to the fact that the aspiration of all the follicles present in the gonads has a direct effect on the quality of the corpus luteum. Therefore, it is easy to establish an insufficiency in the second phase of the cycle which could have serious repercussions in the initial stages of an eventual pregnancy. It has been noted that pregnancies generally develop from oocytes aspirated with at least 3–8 mL of follicular fluid.

If, at the moment of laparoscopy, a burst follicle has already been detected, then it is possible to aspirate the Douglas space first and then the follicle bed in an attempt to pick up the oocyte. The occasional discovery of a burst follicle in the presence of numerous mature follicles can act as an indicator of oocyte maturity (viscous follicular fluid, more layers of radiate crown, etc.).

Furthermore, if a series of patients never display a burst follicle, it can be presumed that the timing of the laparoscopy, adopted by the group, is too early.

Sometimes during the aspiration of the oocyte, there can be certain difficulties which are usually overcome, unless the ovaries are completely inaccessible. It should be noted, however, that conceptions and pregnancies have been obtained with oocytes aspirated by Douglas, often among adhesions and blood clots. When there are delays in the collection of the oocyte, more than 50 min after the administration of anaesthetic they are accompanied by normal pregnancies. This confirms that neither the prolonged use of general anaesthetic nor the presence of intraperitoneal carbon dioxide are seriously damaging for the oocyte.

With the advances of gynaecological echography imaging in the 1980s, many reports were published describing the actual effectiveness of ultrasonically guided oocyte pick-up.

Laparoscopic pick-up, therefore, seemed complicated and produced a rate of success less than 50% per follicle, both for the pick-up of mature oocytes and for the rates of fertilization. In addition, the efficacy of the technique may be obstructed by multiple adhesions or tubal pathologies which block the access to the ovary for the laparoscopic instruments [21, 22].

Transvesical techniques: in 1982, Lenz S., Lauritsen J.G. [23] showed that ultrasounds could be used not only for diagnostic purposes, but also for operative ones. Danish gynaecologists were the first to experiment the efficiency of a new ultrasonically guided percutaneous aspiration method in reaching ovarian follicles and carrying out oocyte pick-up (Fig. 1.19).

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1. Retrieval Theater
2. Quality
3. Follicular Growth
4. Ultrasound Female Pelvic Anatomy

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