On hysteroscopy done 1 year back, uterine cavity was normal. At our clinic, we started with follicular growth and endometrial thickness monitoring in natural cycle. Doppler for endometrial blood flow around the time of ovulation was suggestive of absent flow in zones 2, 3, and 4 of endometrium (Applebaum criteria).4,5 An attempt to improve the blood flow was made by starting Aspirin 75 mg, vitamin E, and Pentoxyfylline.6 However, repeat Doppler around the time of implantation did not show any improvement. In the next cycle, successful ovulation induction with gonodatropins was done, and trigger was given when the follicle was 18 mm, followed by intrauterine insemination.
Country
Approval Status
Notes
USA
Off-label use permitted
Not FDA approved specifically for females
European Union
Restricted, off-label
Prescribed under specialist supervision
Canada
Approved for erectile dysfunction but off-label for females
Australia
Not approved
Approved only for men
Luteal support was given with oral estrogen, progesterone, and vaginal Sildenafil citrate 25 mg (Alivher®; Akumentis Healthcare Ltd., Mumbai, India) twice a day in view of decreased endometrial blood flow in the previous cycle, which may be one of the causes of repeated abortions.7 Doppler for endometrial blood flow around the time of implantation (7–8 days after ovulation) showed good flow in all the zones.
Methods and Objectives
On hysteroscopy done 1 year back, uterine cavity was normal. At our clinic, we started with follicular growth and endometrial thickness monitoring in natural cycle. Doppler for endometrial blood flow around the time of ovulation was suggestive of absent flow in zones 2, 3, and 4 of endometrium (Applebaum criteria).4,5 An attempt to improve the blood flow was made by starting Aspirin 75 mg, vitamin E, and Pentoxyfylline.6 However, repeat Doppler around the time of implantation did not show any improvement. In the next cycle, successful ovulation induction with gonodatropins was done, and trigger was given when the follicle was 18 mm, followed by intrauterine insemination. Luteal support was given with oral estrogen, progesterone, and vaginal Sildenafil citrate 25 mg (Alivher®; Akumentis Healthcare Ltd., Mumbai, India) twice a day in view of decreased endometrial blood flow in the previous cycle, which may be one of the causes of repeated abortions.7 Doppler for endometrial blood flow around the time of implantation (7–8 days after ovulation) showed good flow in all the zones.
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Serum β-human chorionic gonadotropin test done 14 days later confirmed the pregnancy. Sildenafil citrate was stopped on confirmation of pregnancy. Ultrasound at 12 weeks for nuchal translucency, nasal bone, and dual marker test were normal. Patient was called for follow-up visits every 3 weeks. Ultrasound for congenital malformation at 20 weeks did not reveal any abnormality.
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Fetal weight at that time was 440 g, and amniotic fluid index (AFI) was 10. Repeat ultrasound at 24 weeks was suggestive of oligohydramnios (AFI 6) with a fetal weight of 490 g (less than fifth percentile). Color Doppler in umbilical arteries showed normal systolic/diastolic (S/D) ratio, pulsatility index, and resistive index. However, there was notching seen in the uterine artery Doppler study. Investigations such as complete blood count, blood sugars, liver function test, renal function test, urine routine, and microscopy were within normal limits. Serum β-human chorionic gonadotropin test done 14 days later confirmed the pregnancy.
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Sildenafil citrate was stopped on confirmation of pregnancy. Ultrasound at 12 weeks for nuchal translucency, nasal bone, and dual marker test were normal.
Two Medicines
Sildenafil citrate by augmenting feto-placental blood flow in the setting of placental vascular insufficiency helps in increasing the AFI,13 and this is one of the reasons why patients with oligohydramnios and FGR may benefit from sildenafil citrate. It increases the window of fetal maturity and hence reduces neonatal morbidity and mortality due to prematurity. Further studies and randomized controlled trials are needed to validate its usefulness and safety. In our case, the patient had persistent thin endometrium prior to conception and later also developed abnormal feto-placental blood flow and FGR. Whether there is any correlation between the two needs to be further researched and studied.
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The authors are grateful to Mr Sandesh Kamdi for his assistance during the writing of the manuscript. The authors report no conflicts of interest in this work. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, 3.0) License. By accessing the work you hereby accept the Terms.
Common Side Effects
Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms. A total of 80 Patients who meet these conditions will enter the study and be divided into two groups based on randomized tables. Group A : 40 women are given oral estradiol valerate tablets 2mg 6-8 hourly from the day 2-14 of the cycle to prepare the endometrium Group B : 40 women are give sildenafil citrate 25mg vaginally every 6 hours (a half of 50 mg tablet is crushed and dissolved in 2cc of distilled water and injected in to vagina) starting from day 2-14 of the cycle, in addition to oral 2mg of estradiol valerat 6-8 hourly from the day 2-14 of the menstrual cycle . Estrogen and progesterone (prontogest 400mg pessaries ) are given 3 days prior to embryo transfer. Patient was called for follow-up visits every 3 weeks. Ultrasound for congenital malformation at 20 weeks did not reveal any abnormality. Fetal weight at that time was 440 g, and amniotic fluid index (AFI) was 10. Repeat ultrasound at 24 weeks was suggestive of oligohydramnios (AFI 6) with a fetal weight of 490 g (less than fifth percentile).
Sildenafil citrate tablets should be taken with water, not with food.
Always follow the healthcare provider’s dosage instructions precisely.
Use sildenafil only under medical supervision if you have health issues.
Patients should start with lowest effective doses to assess response.
Report any signs of allergic reactions like rash or swelling immediately.
Regular check-ups can monitor for any cardiovascular changes.
Always verify the legitimacy of the medication source.
Sildenafil may cause hypotension in susceptible women.
Consider lifestyle modifications to enhance sexual health benefits.
The drug's effects typically last 4-6 hours.
Be cautious of counterfeit sildenafil products available online.
Educate yourself on potential drug interactions before use.
Color Doppler in umbilical arteries showed normal systolic/diastolic (S/D) ratio, pulsatility index, and resistive index. However, there was notching seen in the uterine artery Doppler study. Investigations such as complete blood count, blood sugars, liver function test, renal function test, urine routine, and microscopy were within normal limits. Her blood pressure was normal; there was no peripheral pitting edema or proteinuria and hence no evidence of preeclampsia. The couple was informed regarding the guarded prognosis of pregnancy, and written informed consent was obtained voluntarily. The patient was kept on bed rest and given vitamin supplements, intravenous amino acid infusions, and nitric oxide donor (L-arginine sachets). Ultrasound at 26 weeks showed an estimated fetal weight of 550 g and an AFI of 4.5. Color Doppler showed an increased S/D ratio in the umbilical arteries with brain-sparing effect in the middle cerebral artery (MCA) as shown in Figures 1 and 2. A repeat ultrasonography at 27 weeks showed reduction in diastolic flow in the umbilical arteries. Figure 3 shows the pfizer sildenafil 100 ultrasonography Doppler image with reduced blood flow at the myometrial placental junction at diagnosis of intrauterine growth restriction. In view of grave prognosis of the pregnancy and unavailability of any other established definitive treatment, the couple was counseled regarding the limited role and experimental nature of Sildenafil citrate in oligohydramnios and FGR. After detailed counseling, the couple opted for Sildenafil citrate 25 mg vaginally twice a day.
Latest Topics
Sildenafil is discontinued 48-72 hours prior to the embryo transfe due sildenafil may have some detrimental effects on endometrium in the implantation window A total of 80 Patients who meet these conditions will enter the study and be divided into two groups based on randomized tables. Sildenafil is discontinued 48-72 hours prior to the embryo transfe due sildenafil may have some detrimental effects on endometrium in the implantation window. For assessing endometrial vascularity (on day 14 of cycle), two dimension power Doppler characteristics as normal quality of color, color gain-3.4, pulse repetition frequency of 600Hz and wall motion filter of 50Hz are applied in all examinations. By following Applebaum's zones of vascularity for categorizing endometrial vasculaity: Zone 1 vascularity-When blood vessls reach the hypoechoic endometrio-myometria junction, Zone 2 vascularity when the vessels reach the outer hyperechoic line of en-dometrium, Zone 3 vascularity when it reach the intervening hypoechoic area, Zone 4 vascularity when the vessels are seen reaching the central echogenic line . After 5 days when the endometrial pattern is triple line pattern (trilaminar) and endometrial thickness is more than 8mm,embryos will be transferred. Repeat ultrasound at 28 weeks showed an improvement in blood flow and an increase in AFI to 6.5 with a fetal weight of 680 g after starting sildenafil citrate as shown in Figure 4. The umbilical artery diastolic flow improved after 2 weeks of therapy, with no brain-sparing effect in MCA; however, the S/D ratio was >3. Furthermore, ultrasound at 30 weeks showed an AFI of 7.5 and a fetal weight of 1,000 g. The patient also experienced a subjective increase in perception of fetal movements. All medications were continued with weekly monitoring of fetal weight and AFI. Gradually at 31 weeks, there was further decrease in pulsatility index, and S/D ratio was <3, in both umbilical and MCAs as shown in Figures 5 and 6. The fetal well-being was continuously monitored using biophysical profile every 2 weeks. Sildenafil citrate therapy was stopped at 36 weeks. An elective cesarean section was done at 37th week for breech presentation, and a healthy female child of 2.3 kg was delivered. Baby cried immediately after birth, and Apgar score was 7/10 and 9/10 at 1 and 5 minutes, respectively. Placenta was examined after delivery; on gross examination, it was smaller in size (400 g) with areas of calcifications and increased thickness of membranes.
Sildenafil citrate can be prescribed off-label for female sexual dysfunction.
Consult a doctor before using sildenafil citrate tablets for women.
Side effects in women may include headache, flushing, or nasal congestion.
Sildenafil works by increasing blood flow to enhance female arousal.
Dosage for women varies; always follow medical advice.
Sildenafil tablets may interact with other medications, like nitrates.
Not approved by FDA specifically for female sexual dysfunction.
Use with caution in women with heart conditions or high blood pressure.
Possible benefits include improved libido and vaginal blood flow.
Sildenafil should be taken on an empty stomach for best results.
Long-term safety of sildenafil in women is not well established.
Store sildenafil citrate tablets in a cool, dry place out of children’s reach.
On histopathological examination, there were areas of infarction. The maternal and neonatal courses were uneventful. We have followed up the child up to 14 months with normal mental and physical development. Adequate placental blood flow is essential for the optimal delivery of nutrients from mother to fetus and for growth of conceptus. Restricted fetal growth results from pathophysiological and environmental factors, which alters uteroplacental blood flow, placental function, and therefore, nutrient availability to the fetus.8,9 There are still limited data on the efficacy of sildenafil citrate for treatment of FGR.
Before Using
The fetal well-being was continuously monitored using biophysical profile every 2 weeks. Sildenafil citrate therapy was stopped at 36 weeks. An elective cesarean section was done at 37th week for breech presentation, and a healthy female child of 2.3 kg was delivered. Baby cried immediately after birth, and Apgar score was 7/10 and 9/10 at 1 and 5 minutes, respectively. Placenta was examined after delivery; on gross examination, it was smaller in size (400 g) with areas of calcifications and increased thickness of membranes.
Cialis Soft Tabs
On histopathological examination, there were areas of infarction. The maternal and neonatal courses were uneventful. We have followed up the child up to 14 months with normal mental and physical development. Adequate placental blood flow is essential for the optimal delivery of nutrients from mother to fetus and for growth of conceptus. Restricted fetal growth results from pathophysiological and environmental factors, which alters uteroplacental blood flow, placental function, and therefore, nutrient availability to the fetus.8,9 There are still limited data on the efficacy of sildenafil citrate for treatment of FGR.
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In our case, we found sildenafil citrate useful in pregnancy complicated by severe oligohydramnios with FGR probably as it improves the placental perfusion. Sildenafil citrate, a specific phosphodiesterase-5 inhibitor, has been proposed as a potential therapeutic strategy to maintain placental function and emerging as a potential candidate for the treatment of intrauterine growth restriction.10 In this case of previous pregnancy losses and thin endometrium, vaginal sildenafil citrate improved the uterine artery blood flow and endometrial thickness and hence reduced the chances of miscarriages.7 Further, when there was problem with the placental perfusion in second trimester, we restarted vaginal sildenafil citrate. Studies have shown that it helps in improvement of uteroplacental blood flow and in turn improves the fetal weight3,11,12 by causing vasodilatation of the intra-myometrial and intra-placental blood vessels. Increased uteroplacental blood improves the delivery of oxygen and other nutrients to fetus, which results in improved growth and development. However, there is no sildenafil white definitive treatment to improve the blood flow to the fetus.8 Our case also showed a consistent increase in fetal weight and AFI with sildenafil citrate without any adverse fetal outcome. In our case, we found sildenafil citrate useful in pregnancy complicated by severe oligohydramnios with FGR probably as it improves the placental perfusion. Sildenafil citrate, a specific phosphodiesterase-5 inhibitor, has been proposed as a potential therapeutic strategy to maintain placental function and emerging as a potential candidate for the treatment of intrauterine growth restriction.10 In this case of previous pregnancy losses and thin endometrium, vaginal sildenafil citrate improved the uterine artery blood flow and endometrial thickness and hence reduced the chances of miscarriages.7 Further, when there was problem with the placental perfusion in second trimester, we restarted vaginal sildenafil citrate. Studies have shown that it helps in improvement of uteroplacental blood flow and in turn improves the fetal weight3,11,12 by causing vasodilatation of the intra-myometrial and intra-placental blood vessels. Increased uteroplacental blood improves the delivery of oxygen and other nutrients to fetus, which results in improved growth and development. However, there is no sildenafil white definitive treatment to improve the blood flow to the fetus.8 Our case also showed a consistent increase in fetal weight and AFI with sildenafil citrate without any adverse fetal outcome. Sildenafil citrate by augmenting feto-placental blood flow in the setting of placental vascular insufficiency helps in increasing the AFI,13 and this is one of the reasons why patients with oligohydramnios and FGR may benefit from sildenafil citrate. It increases the window of fetal maturity and hence reduces neonatal morbidity and mortality due to prematurity. Further studies and randomized controlled trials are needed to validate its usefulness and safety. In our case, the patient had persistent thin endometrium prior to conception and later also developed abnormal feto-placental blood flow and FGR. Whether there is any correlation between the two needs to be further researched and studied. The authors are grateful to Mr Sandesh Kamdi for his assistance during the writing of the manuscript. The authors report no conflicts of interest in this work. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, 3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms. A total of 80 Patients who meet these conditions will enter the study and be divided into two groups based on randomized tables.
Chemical synthesis
Her blood pressure was normal; there was no peripheral pitting edema or proteinuria and hence no evidence of preeclampsia. The couple was informed regarding the guarded prognosis of pregnancy, and written informed consent was obtained voluntarily. The patient was kept on bed rest and given vitamin supplements, intravenous amino acid infusions, and nitric oxide donor (L-arginine sachets). Ultrasound at 26 weeks showed an estimated fetal weight of 550 g and an AFI of 4.5. Color Doppler showed an increased S/D ratio in the umbilical arteries with brain-sparing effect in the middle cerebral artery (MCA) as shown in Figures 1 and 2.
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A repeat ultrasonography at 27 weeks showed reduction in diastolic flow in the umbilical arteries. Figure 3 shows the pfizer sildenafil 100 ultrasonography Doppler image with reduced blood flow at the myometrial placental junction at diagnosis of intrauterine growth restriction. In view of grave prognosis of the pregnancy and unavailability of any other established definitive treatment, the couple was counseled regarding the limited role and experimental nature of Sildenafil citrate in oligohydramnios and FGR. After detailed counseling, the couple opted for Sildenafil citrate 25 mg vaginally twice a day. Repeat ultrasound at 28 weeks showed an improvement in blood flow and an increase in AFI to 6.5 with a fetal weight of 680 g after starting sildenafil citrate as shown in Figure 4.
Cialis Brand
The umbilical artery diastolic flow improved after 2 weeks of therapy, with no brain-sparing effect in MCA; however, the S/D ratio was >3. Furthermore, ultrasound at 30 weeks showed an AFI of 7.5 and a fetal weight of 1,000 g. The patient also experienced a subjective increase in perception of fetal movements. All medications were continued with weekly monitoring of fetal weight and AFI. Gradually at 31 weeks, there was further decrease in pulsatility index, and S/D ratio was <3, in both umbilical and MCAs as shown in Figures 5 and 6. Group A : 40 women are given oral estradiol valerate tablets 2mg 6-8 hourly from the day 2-14 of the cycle to prepare the endometrium Group B : 40 women are give sildenafil citrate 25mg vaginally every 6 hours (a half of 50 mg tablet is crushed and dissolved in 2cc of distilled water and injected in to vagina) starting from day 2-14 of the cycle, in addition to oral 2mg of estradiol valerat 6-8 hourly from the day 2-14 of the menstrual cycle . Estrogen and progesterone (prontogest 400mg pessaries ) are given 3 days prior to embryo transfer.
Statistical Analysis
All patients have a luteal phase support by giving a daily doses of estradiol valerat 2mg oral daily and 100mg progesterone (prontogest 100mg ampoule ) as an intramuscular which will be continued two weeks after the em-bryos transfer. In case BHCG is tested and proved to be positive, estradiol valerat and progesterone are continueed until the 11th week of pregnancy. Sildenafil is discontinued 48-72 hours prior to the embryo transfe due sildenafil may have some detrimental effects on endometrium in the implantation window A total of 80 Patients who meet these conditions will enter the study and be divided into two groups based on randomized tables. Sildenafil is discontinued 48-72 hours prior to the embryo transfe due sildenafil may have some detrimental effects on endometrium in the implantation window. For assessing endometrial vascularity (on day 14 of cycle), two dimension power Doppler characteristics as normal quality of color, color gain-3.4, pulse repetition frequency of 600Hz and wall motion filter of 50Hz are applied in all examinations. By following Applebaum's zones of vascularity for categorizing endometrial vasculaity: Zone 1 vascularity-When blood vessls reach the hypoechoic endometrio-myometria junction, Zone 2 vascularity when the vessels reach the outer hyperechoic line of en-dometrium, Zone 3 vascularity when it reach the intervening hypoechoic area, Zone 4 vascularity when the vessels are seen reaching the central echogenic line .
Before taking this medicine
After 5 days when the endometrial pattern is triple line pattern (trilaminar) and endometrial thickness is more than 8mm,embryos will be transferred. All patients have a luteal phase support by giving a daily doses of estradiol valerat 2mg oral daily and 100mg progesterone (prontogest 100mg ampoule ) as an intramuscular which will be continued two weeks after the em-bryos transfer. In case BHCG is tested and proved to be positive, estradiol valerat and progesterone are continueed until the 11th week of pregnancy.
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