Bilateral tubal obstruction, infertile ovarian transition stimulation syndrome occurred in fresh cycle of in vitro fertilization embryo transfer (IVF-ET), and conception after frozen embryo transfer 1. Clinical diagnosis and treatment The patient Fan, 32 years old, was first seen in June 2003, complaining of infertility for 4 years after ectopic pregnancy surgery. The patient was married for 6 years, had 1 abortion, and had her right uterine horn lesion removed 4 years ago due to a ruptured pregnancy in the right uterine horn. She had not been pregnant since the operation without contraception. Menstrual history, menstruation 3-5 days/35-40 days, moderate menstrual flow, no dysmenorrhea. Past history, personal history, family history is not special; Physical examination: T: 36.5 ℃, P: 76 beats/min, R: 18 beats/min, BP: 110/70 mmHg. General condition is OK, clear, spirit is OK, heart and lungs (-), abdominal tenderness, liver and spleen are not found; Gynecological examination: normal vulvar development, vaginal patency, cervix is smooth, hypertrophied, posterior body of the uterus, poor mobility, double adnexa is not found obvious abnormality Gynecologic examination: normal development of the vulva, smooth vagina, hypertrophy, posterior position of the uterus, poor mobility, no obvious abnormalities in both adnexa. Female basic endocrine: FSH: 5.3mIU/ml, LH: 7.63mIU/ml, PRL: 13.8ng/ml, T: 0.2ngl/dl, E2: 65.51pg/ml. Hysterosalpingography suggests that the uterine cavity is triangular, with a rounded right corner, and bilateral tubes are not visible from the proximal end, suggesting that the tubes are blocked bilaterally. Husband’s semen routine showed normal semen. IVF-ET was proposed, using the long protocol of superovulation, the fifth day of the menstrual cycle, Momoflurane 1 tablet per day for 21 days, starting on the 21st day of the menstrual cycle, travastatin 0.1mg, subcutaneous injection, every other day, to the next menstrual period 2 changed to a daily injection of 0.05mg until the day of the HCG injection. Genetically recombinant human follicle stimulating hormone 150IU was injected intramuscularly once a day starting from the 3rd day of menstruation. Vaginal ultrasound on the 8th day of menstruation showed that: endometrial thickness: 0.8cm,A type, right follicles: 1.2cm1,1.1cm2,1.0cm3, and 0.8-0.9cm8; left follicles: 1.2cm2,1.1cm2,1.0cm3, and 0.8-0.9cm8. 0.9cm8. Gave 150IU of folinafine for 3 days, ultrasound again: endometrial thickness: 0.9cm, type A, right follicle 1.6cm1, 1.5cm4, 1.3cm3, 1.2cm4; left follicle: 1.5cm2, 1.2cm1, 1.3cm3, 1.2cm4; and then 150IU of urocortin, 13th day of menstruation. Endometrial thickness: 1.0cm, type A, right follicle 1.8cm1, 1.7cm2, 1.65cm1, 1.5cm3, 1.4cm4; left follicle: 1.75cm2, 1.65cm3, 1.5cm3, 1.4cm1, HCG10000IU, intramuscular injection, on September 9, 2003, the eggs were collected, 24 eggs, 18 embryos. Eggs were retrieved on September 9, 2003, 24 eggs were obtained and 18 embryos were formed. 60mg of progesterone was given intramuscularly from the day of egg retrieval to support the corpus luteum once a day, and 2 embryos were transferred under the instructions of abdominal ultrasound on the 3rd day after egg retrieval, and the remaining embryos were frozen and preserved. The transfer went smoothly. Luteal support was continued after transfer. Five days after the transfer, the patient experienced lower abdominal distension and discomfort, nausea, vomiting, and low urine output, and abdominal ultrasound indicated that the bilateral ovaries were enlarged in size: the right side: 10.2×6.7 cm, and the left side: 9.6×6.8 cm, with multiple cystic translucent areas, and a large amount of free fluid was seen in the pelvic cavity, and the blood count was: erythrocyte pressure accumulation of 56%. Diagnosis: ovarian transition stimulation syndrome after in vitro fertilization embryo transfer. She was admitted to the hospital for treatment. After admission, the patient was given intravenous fluids, albumin infusion, diuresis, transvaginal ovarian luteal cyst puncture, and ascites release, etc. Urine HCG was negative 14 days after the transplantation, suggesting infertility. The patient’s conscious symptoms such as abdominal distension gradually disappeared, and the size of the ovary was reduced. The patient was hospitalized for 7 days and discharged from the hospital. 2 months later, she underwent frozen embryo transfer in natural cycle, and the frozen embryo was resuscitated and transplanted 3 days after ovulation. 14 days after transplantation, the patient was found positive for urinary HCG, and the blood β-HCG was 318.3 mIU/ml, and 35 days after the transplantation, vaginal ultrasound suggested intrauterine pregnancy with a single pregnancy, and the size of the gestational sac was 2.5×2.7 cm, and the fetal heartbeat was good, and the patient was followed up on 70 days after the transplantation by vaginal ultrasound: intrauterine pregnancy, and the diameter of the fetal diameters was 2.1 cm and the fetal heartbeat was good, and the fetal heartbeat was good. Fetal biparietal diameter was 2.1 cm, fetal heartbeat was good, and amniotic fluid was moderate. Regular labor and delivery, cesarean section at 39 weeks of gestation 1 baby girl weighing 3700 grams. She had a normal appearance and development. 2.Discussion Ovarianhyperstimulationsyndrome (OHSS) is the most serious complication during ovulation promotion, and is almost always a medical complication. Ovarian hyperstimulation produces large amounts of steroid hormones, significant enlargement of the ovaries, increased vascular permeability, leakage of protein-rich fluids into the vascular space, hemoconcentration, and edema of the “third space”, which can be life-threatening. After the use of in vitro fertilization and embryo transfer (IVF-ET), the incidence of moderate OHSS is 3.0%-6.0%, and the incidence of severe OHSS is 0.1%-2.0%, and with the wide application of IVF-ET, the incidence of severe OHSS tends to increase. The incidence of severe OHSS has a tendency to increase with the wide application of IVF-ET. The diagnostic criteria were based on the OHSS classification criteria proposed by GOLAN et al. (1989) as the diagnostic criteria. Moderate: nausea, vomiting, abdominal distension, pain, and dyspnea were present, and ultrasound showed that the diameter of the ovary was 10-12 cm, and there was a moderate amount of peritoneal fluid in the pelvic cavity. Severe: all the symptoms of excessive fluid accumulation in the third interstitial space, such as abdominal fluid, pleural fluid, etc., with an ovarian diameter >12 cm. Severe cases present with ARDS, hepatic-renal failure, and embolism.The main pathophysiological features of OHSS are manifested in the following way: due to damage to the capillary wall, the vascular permeability is increased, which leads to leakage of fluid from the vessels, causing pleural fluid, ascites, and diffuse edema, etc., which in turn leads to a decrease in blood Volume reduction, blood concentration, insufficient perfusion of renal blood flow, oliguria, accompanied by electrolyte disorders, azotemia and thrombosis, etc. Finally, death can be caused by renal failure and adult respiratory distress syndrome. Treatment: (1) Monitor vital signs every morning to monitor blood pressure, pulse, temperature and respiration, abdominal circumference, weight changes. Monitor 24h urine output daily, if the daily urine output <500mL adjusted to monitor 24h in and out. Check the blood routine, liver and kidney function, blood electrolyte condition at appropriate time. According to the condition of ultrasound monitoring to understand the pelvic, abdominal and pleural effusion. (2) Dilatation therapy for erythrocyte hematocrit (HCT) >0.40 or 24h urine volume <1000mL, then dilatation therapy. Intravenous infusion of 6% medium molecular hydroxyethyl starch 130/0.4 (Viron) at a dose of 1000mL/d, HCT<0.40 is changed to 500mL/d, and the drug is discontinued until the HCT is equal to 0.35. Low molecular dextrose is commonly used as a volume expansion drug, and it can also reduce blood viscosity and improve microcirculation to prevent thrombosis. However, low molecular dextrose affects coagulation function and is contraindicated in people with severe bleeding tendency, and low molecular dextrose does not increase the plasma colloid osmotic pressure. Albumin accounts for 80% of the plasma colloid osmotic pressure and regulates the dynamic balance of water between tissues and blood vessels. Due to the high molecular weight of albumin, compared with salts and water, the rate of transmission through the membrane is slow, so that the colloid osmotic pressure of albumin and the static pressure of the capillary counterbalance, so as to maintain a normal and constant blood volume; at the same time in the blood circulation, 1g of albumin can be retained in 18mL of water, every 5g of albumin to retain water in the circulation of water is equivalent to about 100mL of plasma or 200mL of whole blood products, but the albumin However, albumin is easily infected with blood-borne diseases such as Hepatitis A, Hepatitis B, and HIV, and is relatively expensive. 6% medium molecular hydroxyethyl starch 130/0.4 (Viron) is an ideal plasma substitute for volume therapy, and its volume expansion is more favorable to tissue oxygenation, improves microcirculation, and reduces endothelial cell swelling. Clinical data show that it has a minimal effect on coagulation and improves capillary permeability with appropriately sized and shaped molecular plugs to occlude capillaries. It also inhibits the expression of inflammatory mediators and reduces leukocyte-endothelial cell interactions (preventing neutrophil adhesion). Several studies have shown that volume replacement therapy with hydroxyethyl starch results in a decrease in the release of pro-inflammatory factors, a decrease in the expression of adhesion molecules on epithelial cells and a decrease in the concentration of soluble adhesion molecules. These effects can improve microcirculation and reduce endothelial activation, thereby decreasing endothelial damage and reducing the inflammatory response.The average duration of disease in OHSS treated with albumin is (13±6.8)d ⑶ Transabdominal wall or transvaginal puncture and fluid release may be considered for the following conditions: a Swollen and tense abdomen, which results in severe discomfort or pain for the patient. b Impaired lung function, dyspnea, and thoracic cavity effusion. c Impaired renal function, unresponsive to rehydration and other treatments, and persistent oliguria. d In patients with severe OHSS, the oliguria and renal impairment continue to worsen after normalization of blood volume. After abdominal ultrasound localization, the patient was suctioned at a negative pressure of 300-400 mmHg at a rate of about 100 mL/min until the ascites was suctioned cleanly. After the operation, the patient rested in semi-recumbent position for about 10min, and returned to the ward if there was no discomfort. If the patient's ovarian volume is large, multiple cystic acoustic areas in the ovary can be transvaginal luteal cyst puncture of the ovary at the same time as ascites aspiration, the patient to take the cystotruncal position, the head is high and the buttocks are low, the fluid accumulates in the pelvis, which is conducive to the suction, the patient in this case, first of all, the abdominal wall through the abdominal wall to release ascites 1 time, about 1,500 ml, 24 hours of age, the symptoms again aggravated, that is, to take the transvaginal discharge of fluids at the same time as the luteal cyst of the ovary puncture. The fluid was drained for 2500 ml, and the patient immediately felt symptomatic relief after the operation. According to the patient's clinical manifestations to determine the interval between operations. (4) transchest wall fluid discharge treatment of a very small number of patients with clinical symptoms mainly pleural effusion, clinical manifestations of irritating cough. This part of the patient can be ultrasound localization under the transchest wall fluid discharge treatment. When the patient holds his head on a comfortable table, ultrasound positioning with a puncture needle from the chest wall of the rib gap into the pleural cavity (between the lungs and the chest wall), to extract the pleural cavity of the fluid, generally not more than 1000mL at a time, the suction speed of about 30mL/min. according to the patient's clinical symptoms to determine the interval between surgeries. (5) Other medications are given to the patient aspirin 50mg/d and prednisone 5mg/d for preventing thrombosis and stopping fluid infiltration into the abdomen and chest. (6) Diuretic therapy If the patient's water intake, dilatation is adequate, and 24-h urine output is <1000 mL after treatment with abdominal drainage, 10 μg of furosemide can be pushed intravenously to prevent renal failure. (7) Termination of pregnancy is mandatory if the patient is not relieved and deteriorates further after symptomatic treatment with aggressive volume expansion and abdominal fluid release. OHSS is a self-limiting disease, and remission of clinical symptoms coincides with a decrease in residual serum levels of exogenous HCG after egg maturation. Therefore, once pregnancy-induced increases in endogenous HCG exacerbate OHSS or induce late-onset OHSS, most patients do not experience serious sequelae after early diagnosis, prompt, dynamic, and prudent fluid management, prophylaxis of thrombosis, and treatment of peritoneal fluid collections. However, unpredictable and serious complications sometimes occur. Therefore, prevention of OHSS is necessary and important. In this study, we found that multiparous OHSS patients had a long duration and high disease severity, which may be related to the high endogenous HCG in multiparous patients, which can stimulate the development of OHSS. Therefore, single blastocyst transfer can be performed in patients at high risk for OHSS. Currently, there is no clear predictor of OHSS, and most scholars believe that the combined application of E2 and ultrasonography is the best predictor of OHSS occurrence. In this study, we found that patients with high estrogen on the day of HCG injection (E2>4000 pg/mL) had a long course of OHSS, so the authors suggest that fresh embryo transfer should be canceled in patients with E2>4000 pg/mL on the day of HCG injection, and frozen embryos should be frozen and rested for 2 months and then frozen embryo transfer should be performed.