Infertility and Ventriculoperitoneal Shunt Azim et al 90 Ventriculoperitoneal (VP) shunt is the main treat- ment modality for hydrocephalus or pseudotumor cerebri. 1 Increasing numbers of women with cerebrospinal fluid (CSF) shunts survive to sexual maturity and childbearing age and thus may be faced with decisions regarding con- ception. 2–4 Although several reports on the occurrence and outcome of pregnancy in shunt-dependent patients were cited, no literature addresses infertility in this population. Case Reports Two women with long-standing VP shunt underwent laparoscopy for primary infertility. Patient No. 1 A 23-year-old woman had 3 years of unprotected inter- course with a single partner. Her history was significant for spina bifida and hydrocephalus. A VP shunt was placed in childhood and revised several times, the last time 7 years before we saw her. She was incontinent to urine and stools. Her menstrual history was consistent with oligomenorrhea, with menstruation for 4 days every 2 to 3 months. She denied galactorrhea, excessive hair growth, and hot flushes. She failed to ovulate after therapy with clomiphene citrate 50 to 100 mg for 3 months. She had no history of pelvic inflammatory disease (PID). The husband’s semen analy- sis was normal. Her general examination was unremarkable (weight 68.2 kg, height 145 cm). Thyroid gland was not enlarged. She had a 2-cm horizontal abdominal scar 1.5 cm below and on the right side of umbilicus. Pelvic examination was unremarkable and pelvic ultrasound scan was normal. Hor- mone profile consisting of follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hor- mone (TSH), prolactin, and total thyroid, was within nor- mal limits. Midluteal serum progesterone in a clomiphene cycle was 2.2 ng/mL. Hysterosalpingogram (HSG) revealed a normal uterine cavity and patent left fallopian tube with localization of dye around its fimbriae and right cornual block. An earlier intravenous pyelogram showed a bifid lumbosacral spine and normal renal function with no obstructive uropathy. At laparoscopy, abdominal entry with a 10-mm Surgi- port was performed after carbon dioxide pneumoperito- neum. Extensive adhesive disease was seen. Numerous loops of small intestine were adherent to the anterior abdom- inal wall, especially on the right side corresponding to the shunt scar. Another 5-mm Surgiport was introduced under direct vision. With laparoscopic scissors we were able to free some loops of small intestine from the abdominal wall to enable us to ensure there was no injury to small intes- tine. After partial enterolysis, complete obliteration of the cul-de-sac was evident. Both ovaries and fallopian tubes could not be visualized. The peritoneal end of the shunt was not seen. Laparoscopic adhesiolysis and tubal perfusion were abandoned. The patient was admitted for 23-hour observation. Her postoperative course was uneventful. At the time of her follow-up appointment she was offered in vitro fertilization with embryo transfer (IVF/ET), but she declined. Patient No. 2 This 26-year-old woman had primary infertility of 2 years’ duration. Her medical history was significant for hydrocephalus, which was treated with VP shunt during childhood. Menarche was at age 13 and her cycle was reg- ular. She had no history of PID. Her general examination was unremarkable (weight 72 kg, height 162 cm). She had a 2.5-cm, horizontal abdomi- nal scar approximately 5 cm below and to the right side of the umbilicus. Pelvic examination was unremarkable and vaginal ultrasound scan was normal. Her cycle day 3 serum FSH and LH levels and serum prolactin and TSH levels were normal. An HSG revealed a normal endometrial cavity and patent fallopian tubes with possible bilateral peritubal adhesions as suggested by localization of dye around the tubes. Her husband’s semen analysis was normal. At open laparoscopy, small intestine loops were adhered to the abdominal wall and the procedure was aban- doned. The patient was admitted for 23-hour observation. From IVF Michigan, Flint and Rochester Hills, Michigan; Hurley Medical Center, Center for Reproductive Medicine, Flint, Michigan; and Department of Obstetrics and Gynecology and Reproductive Biology, Michigan State University, College of Human Medicine, East Lansing, Michigan (all authors). Corresponding author Mostafa I. Abuzeid, M.D., Hurley Medical Center, Two Hurley Plaza, Suite 209, Flint, MI 48503. Submitted June 26, 2003. Accepted for publication September 17, 2003. Abstract (JAm Assoc Gynecol Laparosc 2004, 11(1):90–91) Two women with a ventriculoperitoneal shunt had primary infertility. At laparoscopy they both had extensive peritoneal adhesions that made evaluation of pelvic organs impossible and increased the risk of bowel injury. History of ventriculoperi- toneal shunt should be considered a contraindication of laparoscopy. Infertility and Ventriculoperitoneal Shunt Amr Azim, M.D., Mohammad Ashraf, M.D., and Mostafa I. Abuzeid, M.D. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, February 2004, Vol.11 No.1 © 2004 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.