repeated in vitro fertilization ( ivf ) failure together with ovarian hyperstimulation syndrome ( ohss ) is one of the distressing situations leading couples to search for alternative treatment options . for such patients with polycystic ovarian syndrome ( pcos ) who have experienced ovarian hyperstimulation syndrome , mild ovarian stimulation with in vitro oocyte maturation could be a promising alternative . testicular sperm aspiration ( tesa ) of spermatozoa from a known obstructive azoospermic patient is a limiting factor for ivm ( in vitro maturation ) but the couple reported here accepted mild ivf -ivm with tesa . case presentation : in the treatment of a 32-year old woman , 9 immature oocytes were retrieved , 5 in vitro matured oocytes ( maturation rate 55% ) and after fertilization by intracytoplasmic sperm injection ( icsi ) , 3 oocytes ( fertilization rate 60% ) which had two pronuclei and two good quality embryos on day 2 , were transferred . although the number of births from icsi of immature oocytes injected with surgically derived sperm is quite low , the selection of this mode of therapy as an alternative to conventional ivf will overcome the limitations and provides a new option in ivf practice . in vitro oocyte maturation ( ivm ) with a mild ivf program is a well - known laboratory procedure , which has been used in assisted reproductive technologies ( arts ) cycles as an alternative to conventional ivf . although the clinical applications have been limited to cases of pcos who have experienced ohss , it can also be used in normal ovarian reserve patients and in patients who have failed to conceive by conventional art treatments . since ivm needs only mild or no ovarian stimulation , there is no risk of ohss . despite no contraindications , there are hesitations about using ivm in cases with surgical sperm retrieval and selecting tesa - ivm in couples with obstructive azoospermia , but it is an effective treatment option which can result in successful pregnancies and live births ( 1 , 2 ) . since ivm has a limited use in art practice , convincing couples with male factor infertility such as azoospermia for ivm is very difficult . however , the risk of ohss and failed ivf attemps makes the decision for ivm much easier in such couples . the number of cases of ivm in azoospermia is limited in the literature and only limited centers have experience on ivm in azoospermia , thus increasing the number of studies in such cases may encourage ivf centers to use this modality in their ruotine practice . a 32 year old woman and her 37 year old husband presented at clinart ivf center ( trabzon , turkey ) in 2011 with a 7-year history of primary infertility with two failed attempts at tesa - icsi . ultrasound examination on day 3 of the menstrual cycle revealed the existance of bilateral polycystic ovaries . the male was diagnosed with obstructive azoospermia and had undergone surgery for tesa for each icsi attempt . many treatment options were discusssed with the couple together with ivm - tesa but due to a history of ohss in one of the previous attempts , the couple decided to be treated with this treatment modality . there was no history of other medical or surgical diseases and hormonal parameters were as expected ( fsh 6.28 miu / ml , lh 7.73 miu / ml , prl 42.96 ng / ml and tsh 2.68 miu / ml ) . in their first conventional icsi attempt , 26 oocytes were collected , 3 embryos were transferred and following ohss , she had negative  hcg value . in their second attempt at the same center , the hormone parameters of the male supported the previous diagnosis of obstructive azoospermia ( fsh 5.81 miu / ml , lh 5.97 miu / ml , tsh 2.62 miu / ml and prl 13.50 ng / ml ) . the female started a semi ivf - ivm program on day 3 and was given 3 days of 75 iu recombinant fsh ( gonal - f , merck serono , switzerland ) sc for fsh priming together with estrogen support for endometrial thickening . the patient was evaluated on day 6 and on day 8 , repetitively for endometrial triple line pattern and when endometrial thickness of 8 mm was achieved together with follicles less than 12 mm , 250 microgram human chorionic gonadotropin alpha ( ovitrelle , merck serono , switzerland ) was administered subcutaneously for triggering . after 36 hr , 9 immature oocytes were collected and testicular sperm were derived by tesa at the same day of opu under general anesthesia . after filtration and 26 hr after the incubation in ivm culture medium ( origio medicult ivm medium , denmark ) , the oocytes were detached ( denuded ) from the cumulus cell mass and 5 matured oocytes ( 55% maturation rate ) were injected with tesa derived fresh sperm and 3 oocytes with 2 pronuclei ( 60% fertilization rate ) were generated . on the second day , 2 embryos with grade 2 morphology were transferred . first fetal cardiac activity was determined on abdominal ultrasound at 6 weeks and 6 days and the patient had a safe cesarean - section delivery of a healthy male infant ( birthweight 4000 g ) at 38 weeks of gestation . ivm laboratory course ; a : obtained gv oocyte with cumulus corona complex ; b : mii oocyte following ivm ; c : pn stage ; d : transferred embryo immature oocyte collection in a mild ivf program is still controversial for many ivf specialists and the impact of ivm is decreased compared to conventional methods . however , after the failure of conventional attempts , the low costs , no ohss risk and possibility of being repeated in a short time make ivm a tempting prospect for couples ( 1 ) . the most important point in ivm is the optimized culture media since immature oocytes have immature cumulus cells that may lead to diminished nutritional support for oocytes in vitro ( 2 ) . the ivm culture medium is supported by the maternal serum albumin ( 3 ) . as it conforms with healthcare regulations , the study of fadini et al . by tese of noa with ivm and 20 normoovulatory and one pcos patients who underwent 27 ivm cycles . the results of tese on non obstructive azoospermia ( noa ) were compared with conventional icsi in terms of respective pregnancy and fertilization rates and it was concluded that ivm may represent an option in noa cases ( 4 ) . in another study by son et al . , tese - ivm cases were compared with ivm with ejaculated sperm and 21 patients through 24 cycles were evaluated . clinical pregnancies were 37.5% of cases and it was concluded that ivm combined with tese - icsi could be a suitable option for couples with pco and azoospermia ( 5 ) . the introduction of icsi for art treatment has offered azoospermic patients the possibility of pregnancy following surgical sperm removal ( 6 ) . the first live birth from tese - ivm was reported by ahmad kamal et al . in 2001 at mcgill university , canada ( 7 ) . at a recent meta - analysis , the authors showed decreased live birth and implantation rates in comparison to conventional ivf / icsi for patients with various indications for ivm . however , the rates of ovarian hyperstimulation syndrome significantly reduced in studies with patients with polycystic ovary syndrome ( 8) . walls et al . compared fresh , frozen and cumulative cycle outcomes of ivm cycles through an observational study . their results showed similar success rates , particularly in relation to the incidence of miscarriage in fresh ivm cycles and improved success from frozen embryo transfer ( fet ) cycles ( 9 ) . this is the first case of ivm - tesa ever reported in turkey and the successful outcome indicates that ivm could be a good alternative in cases of failed conventional icsi and azoospermia in addition to pcos and ohss .
background : repeated in vitro fertilization ( ivf ) failure together with ovarian hyperstimulation syndrome ( ohss ) is one of the distressing situations leading couples to search for alternative treatment options . for 
 such patients with polycystic ovarian syndrome ( pcos ) who have experienced ovarian hyperstimulation syndrome , mild ovarian stimulation with in vitro oocyte maturation could be a promising alternative . 
 testicular sperm aspiration ( tesa ) of spermatozoa from a known obstructive azoospermic patient is a limiting factor for ivm ( in vitro maturation ) but the couple reported here accepted mild ivf -ivm with tesa.case presentation : in the treatment of a 32-year old woman , 9 immature oocytes were retrieved , 5 in vitro matured oocytes ( maturation rate 55% ) and after fertilization by intracytoplasmic sperm injection ( icsi ) , 3 oocytes ( fertilization rate 60% ) which had two pronuclei and two good quality embryos on day 2 , were transferred . 
 a live pregnancy was observed by ultrasound scan and healthy infant was delivered.conclusion:although the number of births from icsi of immature oocytes injected with surgically derived sperm is quite low , the selection of this mode of therapy as an alternative to conventional ivf will overcome the limitations and provides a new option in ivf practice .