At times, an unexpected complete fertilization failure is observed and ICSI is performed on in vitro matured oocytes (D2 ICSI) the day of fertilization assessment. This fertilization failure is often observed in patients who have had a historical ICSI attempt with successful fertilization. This implies that the fertilization failure at the time of oocyte retrieval (D1) may be due to inadequate in vivo maturation. Here we analyze ovarian superovulation and their eventual effect on unexpected complete failure of fertilization in the study cycle. In a retrospective manner, we compared patients presenting a cycle with failed fertilization on day 1 (D1), and achieved fertilization on day 2. This cycle was also compared to previous, or reference, cycles with successful fertilization. Controls were age-matched and had fertilization on D1. From Jan 2001 to Jan 2004, patients with initial fertilization failure who fertilized the next day (D2 ICSI) were included. Only cycles with ejaculated spermatozoa (non-TESE) were included in the study. Patient age, BMI, proportion of urinary vs. recombinant medication, follicle size, maximum E2 level, oocyte number, in vivo/in vitro maturation time, ICSI operator, embryo quality, and pregnancy outcome were recorded. A total of 22 patients were identified during the three-year span. Twelve of these patients had a reference cycle with fertilization (D1) and were used for comparison. The age-matched controls included 22 patients with successful fertilization on D1. The semen parameters for the study group was an average of 50.8 x 106/ml concentration, 52.8% ± 23 motility, and 4.25 ± 3 morphology. There were no differences in age, type of protocol (agonist or antagonist), gonadotropin dose/type, ICSI operator, follicle size, E2 level, or days of stimulation between the three groups. There was, however, a shorter time lapse between HCG administration and time of ICSI in the study cycle vs. reference and age-matched control, 39h 6’ ± 1h 28’ (M ± SD) vs. 39h 53’ vs. 40h 17’ ± 58’, respectively (P < 0.01). In addition, BMI of the D2 ICSI group were also significantly higher than the age-matched patients (26.7 ± 6 vs. 22.0 ± 2; P < 0.01). There was an impaired pregnancy outcome in the study cycles in comparison to the other two groups. Tabled 1 This current study is the first to explore factors leading to, and resulting from, an unexpected fertilization failure with ICSI. Incubation of in vitro matured oocytes restored fertilization but resulted in extremely poor pregnancy outcome. This is an unsettling finding in a population with proven normal fertilization in historical IVF cycles. A shorter time interval between HCG administration and oocyte injection confirmed that inadequate in vivo maturation was responsible for the oocyte activation failure. Moreover, the presence of a higher BMI identified in the study group may represent an additional challenge in tailoring ovarian superovulation in this category of patients.