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Summary of key findingsof other supporting studies

• Proper storage extends the shelf life of sildenafil tablets.
• Use caution when combining sildenafil with blood pressure medications.
• Female response to sildenafil can depend on psychological factors.
• Always disclose all health conditions before starting therapy.
• The medication may help improve quality of sexual experiences.
• Some women may experience no noticeable change; individual variation exists.
• Sildenafil can create a temporary sense of increased arousal.
• Keep a journal to track effects and side effects.
• Use sildenafil as part of a broader approach to sexual health.
• Avoid taking more than the recommended dose.
• Some evidence indicates sildenafil may reduce sexual pain in women.
• Considering alternative therapies may be beneficial if sildenafil is ineffective.

The clinical pregnancy rate was two-fold higher

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“ Infertility a diseaseof the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse Infertility o Global incidenceof infertility is about 13- 18% o The incidence of infertility steadily increases in women after age 30. o In India, although population growth is a major concern, there are a substantial number of infertile couples. Causes of female factorinfertility o Ovulation disorders (40%) o Aging o Diminished ovarian reserve (DOR) o Polycystic ovary syndrome (PCOS) o Premature ovarian failure o Others Thin endometrium o Adequatethickness of the endometrium is essential to accomplish a successful pregnancy in ART cycles o ‘‘Thin endometrium” defined as an endometrium thickness that can’t reach the threshold for embryo implantation. Thin endometrium o Studiessuggest minimal endometrial thickness of 7 mm, (and preferably > 9 mm) to maximize pregnancy rates o Several reports have shown correlation between a ‘‘thin endometrium’’ and low implantation rates o Clinical pregnancy rates increased gradually from 53% among patients with a lining <9 mm, to 77% among patients with a lining of >16 mm. o Furthermore, thin endometrium causes higher risk of miscarriage Human Fertility 2009;12:198–203.

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Understanding the endometrium Endometrium hastwo layers: o a basalis layer that is adherent to the myometrium o and a functional layer which undergoes different phases during a menstrual cycle o This lining is under the control of estrogen hormone and passes through different phases during the monthly menstrual cycle of female. Understanding the endometrium o Theaverage thickness of endometrium is 8 mm which increases further in pregnancy. Less than 8 mm is considered inadequate o During pregnancy, at least 9 mm of thickness is required to provide a site for proper implantation of fetus. o This thickness not only plays a vital role in the implantation of fetus to the walls of the uterus but also supports the growing baby in the later stages of pregnancy. Consequence of thin endometrium oIf, due to any cause, this lining becomes thin, it becomes impossible for the fertilized egg to get implanted to the wall. in the study group (Sildenafil), compared to

control group but not statistically significant (47.6% vs.

25.9%, P=0.209) All three (A: Vit E,

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Implantation and ongoing pregnancy rates were significantly higher for Group A (29% and 45%) than for Group B (2% and 0). ▪Conclusion: Vaginal administration of sildenafil enhanced endometrial development in 70% of patients studied. High implantation and ongoing pregnancy rates were achieved in a cohort with a poor prognosis for success. Study 03 ▪Study details: In a prospective study, 10 patients in our fertility center gave their informed consent to be treated with vaginal sildenafil citrate suppositories (25 mg) four times per day from the third day of the stimulation protocol to the evening before oocyte retrieval. Summary of key findingsof other supporting studies Sildenafil improved endometrial vascularity and marginally increased pregnancy outcome.

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The clinical pregnancy rates were 20% in SC group and 14% in estrogen group after 3 cycles of IUI (P=0.042) The endometrial vascularity was significantly higher after sildenafil treatment in 21 patients (P<0.01). Embryo transfer was done in 19 women, out of which 9 (47.36%) women conceived Mangal S, Mehirishi S. To study and compare the effect of vaginal sildenafil and estradiol valerate on endometrial thickness, blood flow and pregnancy rates in infertile women undergoing intrauterine insemination. Mishra VV, Choudhary S, Bandwal P, Aggarwal R, Agarwal R, Gandhi K. Vaginal sildenafil: Role in improving endometrial blood flow in women undergoing IVF with frozen – Thawed embryo cycles – A study over three cycles. B: L-arginine, C: Sildenafil) interventions improved uterine

Further information

o This can lead to infertility of a female uterus and pregnancy cannot take place because a fertilized egg needs a strong support for implantation and support for growing into an embryo. Causes of thin endometriallining Thinning of endometrial lining is a serious problem from gynecological point of view. Poor health of endometrial tissue (Any injury, surgery, trauma or infection can cause damage to the endometrial lining) 4. Long term use of birth control pills 5. Signs and symptoms ofthin endometrial lining There are no specific signs and symptoms related to the thin endometrial lining.

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However females suffering from thin over the counter drugs containing sildenafil endometrial lining may present with: 1. Sildenafil ▪Sildenafil is aselective inhibitor of Phosphodiesterase -5 (PDE-5), which is cGMP- specific and responsible for the degradation of cGMP ▪Sildenafil protects cyclic guanosine monophosphate (cGMP) from degradation by cGMP-specific phosphodiesterase type 5 (PDE5) Background The endometrium isthe special epithelial lining of the uterine cavity It has two layers: A superficial functional layer and a deeper basal layer The endometrial growth is reliant on the uterine blood flow Uterine blood flow is closely related with the vascular development of endometrium plays a significant role in the development of a dominant follicle, formation of a corpus luteum, and growth of endometrium This is essential to support endometrial growth after menstruation and to provide a vascularized receptive endometrium for implantation “ In caseswhere ‘‘thin’’ endometrium results from reduced endometrial blood flow, the use of vasoactive substances may increase endometrial perfusion with a consequent improvement in endometrial growth. Rationale for use ▪Endothelialand inducible NO synthase isoforms have been identified in both the vascular endothelium of human endometrium and in the myometrium ▪Vaginally administered sildenafil suppositories could lead to an improvement in uterine blood flow and, in conjunction with controlled ovarian hyperstimulation, lead to estrogen-induced proliferation of the endometrial lining Telfer JF, Irvine GA, Kohnen G, Cambell S, Cameron IT. Expression of endothelial and inducible nitric oxide synthase in non-pregnant and decidualized human endometrium. Vaginal sildenafil (Viagra): a preliminary report of a novel method to improve uterine artery blood flow and endometrial development in patients undergoing IVF. RA-RI and EM in the patients with

• 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.

a thin endometrium Pregnancy rates: 50% in

sildenafil group, 11% in L-arginine, 20% in

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Female internal sex organs Ovaries oThe ovaries are small, paired organs located near the lateral walls of the pelvic cavity. o These organs are responsible for the production of the egg cells (ova) and the secretion of hormones. o The process by which the egg cell (ovum) is released is called ovulation. o The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. Ovulation, conception & implantation oOvulation is the release of egg from the ovaries.

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o Conception/ Fertilization is the union of a human egg and sperm, usually occurring in the ampulla of the fallopian tube. o Implantation is the very early stage of pregnancy at which the conceptus (fertilized embryo) adheres to the wall of the uterus. Implantation o At thisstage of prenatal development, the conceptus is a blastocyst. o It is by this adhesion that the fetus receives oxygen and nutrients from the mother to be able to grow. o Implantation of a fertilized ovum is most likely to occur about 9 days after ovulation, ranging between 6 and 12 days. Vitamin E, and nil in control group

Mechanism of Action of Sildenafil on Endometrium

Sildenafil: potential rolein female infertility due to thin endometrium ▪Sildenafil enhances the effect of NO by inhibiting PDE5 which is responsible for degradation of cGMP. ▪With the use of sildenafil, cGMP levels remain elevated, which leads to vascular relaxation and increased blood flow to improved the endometrial thickness Sher G and Fisch JD. Indications ▪To improve endometrialthickness in female infertility due to thin endometrium Dose and dosage ▪Thinendometrium: Sildenafil citrate 25 mg vaginally every 6 hours from day 8th of the cycle for 5 days (3-10 days) ▪In ART: Vaginal sildenafil citrate suppositories (25 mg) four times per day from the third day of the stimulation protocol to the evening before oocyte retrieval. Study 01 ▪Objective tostudy and compare the effect of vaginal sildenafil citrate and estradiol valerate on endometrial thickness, blood flow and pregnancy rates in infertile women undergoing intrauterine insemination ▪Methodology Comparative prospective study including 100 women with primary or secondary infertility with stimulated cycles undergoing IUI In group A, 50 patients were included and given sildenafil citrate 25 mg vaginally every 6 hours from day 8th of the cycle. In group B, 50 patients were given tablet estradiol valerate 2 mg 6-8 hourly.

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Study 01 ▪Results 64%patients given sildenafil vaginally had vascularity up to zone 3 whereas 48% patients given estradiol valerate orally had zone 3 endometrial vascularity (p value = 0.038) The clinical pregnancy rates were 10 (20%) in group 1 and 7 (14%) in group 2 after 3 cycles of IUI. (p value = 0.042) ▪Conclusion Sildenafil when compared to estradiol valerate has better results as far as endometrial vascularity is concerned and marginally increased pregnancy outcome in patients undergoing IUI Study 02 ▪Objective: Toevaluate the effects of vaginally administered sildenafil on endometrial thickness and IVF outcome in a large cohort of infertile women with poor endometrial development. ▪Intervention: Patients underwent IVF using a long GnRH-a protocol with the addition of sildenafil vaginal suppositories (25 mg, 4 times per day) for 3–10 days. ▪Main Outcome Measures: Peak endometrial development, pregnancy, and implantation rates. Study 02 ▪Results: Of105 patients, 73 (70%; Group A), attained an endometrial thickness of 9 mm whereas 32 (30%; Group B) did not. Kim KR, Sun Lee H, Ryu HE, Park CY, Min SH, Park C, et al.

• Remember that sildenafil is not designed specifically for women; evidence is ongoing.
• Consult your healthcare provider for personalized advice concerning usage.
• Be aware that psychological and physical factors both influence female libido.
• The medication can help improve vaginal blood flow during arousal.
• Regular use without medical supervision is not recommended.
• Some women may experience improved sexual confidence with sildenafil.
• Manage expectations by understanding that results vary widely.
• Do not suddenly stop other medications without doctor approval.
• Educate yourself about symptoms of potential adverse reactions.
• Maintaining overall health can enhance the effectiveness of sildenafil.
• Use caution if combining sildenafil with herbal supplements.
• Ensure comprehensive sexual health assessment before commencing treatment.