IVF With a Thin Uterine Lining: Vaginal Viagra is Often The Answer

09 Nov
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It has been more than a decade since we reported the first IVF baby born following vaginal Viagra treatment for an “insufficient” endometrial lining. Since that time, worldwide, thousands of women with “unexplained IVF failures”, recurrent miscarriages and late pregnancy loss as a result of poor intrauterine growth and development due to thin uterine lining have subsequently gone on to achieve healthy, normal pregnancies.

An endometrial thickness of greater than 9mm at the time of the hCG trigger as determined by vaginal ultrasound, correlates well with an optimal chance of a successful pregnancy following IVF, while a lining of less than 8mm is associated with a poor prognosis. Measurements between 8 and 9mm represent an “intermediate zone” where outcome is somewhat poorer. To be more specific, in my personal IVF practice, I have found over the years that an endometrial lining of under 8mm, is associated with about an 80% reduction in the likelihood of a successful outcome (for any given age group). When the lining thickness at the time of the hCG trigger is 8-9mm (“intermediate”) the comparative birth rate is about 50% lower. Efforts to improve the development of the endometrial lining through administration of estrogen supplementation or aspirin have proved disappointing.

To be effective and safe, Viagra must be administered vaginally and not orally. The reason is that when absorbed vaginally, Viagra immediately enters the uterine blood circulation in a high concentration, and is thus able to improve blood flow and estrogen delivery to the inner (germinal or basal) endometrial lining. From the uterine lining, the Viagra then immediately passes into the systemic blood circulation in a very low concentration, and thus rarely causes any side effects or complications. Conversely, when administered orally, Viagra absorbs from the upper gastrointestinal tract and reaches the systemic circulation in a relatively high concentration and can thus cause side effects. In women with coronary, neural or peripheral vascular disease, it can even result in serious complications.

The recommended dosage is one 20mg vaginal Viagra suppository (inserted high in the vagina), ideally starting soon after menstruation ceases and continuing until the hCG trigger. We recently noted that it is possible to adequately improve a “thin” endometrium with at least 2 days of Viagra therapy.

For embryo recipients who in spite of adequate estrogen therapy to build a uterine lining in preparation for a frozen embryo transfer (or a fresh embryo transfer following an egg donor or gestational surrogacy cycle) have “thin” endometrial linings, Viagra therapy often proves effective. In such patients, treatment should be discontinued on the day that progesterone therapy is initiated.

In my practice I often recommend combining Viagra administration with 5mg of oral terbutaline taken 3 times a day. The latter, by relaxing the uterine muscle allows further improvement in blood flow through the uterus, thereby improving estrogen delivery to the lining. The only problem in using Terbutaline is that some women do not tolerate it well, experiencing severe agitation, tremors and palpitations. In such cases, the terbutaline should be discontinued. Terbutaline should also not be used women who have cardiac disease or in those who have an irregular heart beat.

About 75% of women with “thin” uterine linings see a positive response to treatment within 2-3 days. The ones that do not respond well to this treatment are those who have severely damaged inner (basal/germinal) endometrial linings, such that no improvement in uterine blood flow can coax an improved response. Such cases are most commonly the result of prior pregnancy-related inflammations that sometimes occur post abortally or following infected vaginal and/or cesarean delivery.

Viagra therapy has proven to be a godsend for thousands of woman who, because of a “thin” uterine lining, would otherwise never be able to successfully complete the journey “from infertility to family”.

170 Comments

  • Anne says:

    Hello Dr. Sher,
    I fell pregnant with my very first IVF but unfortunately had to have a D&C for a missed abortion. Since then I have a thin endometrium (approx. 7,5mm before ovulation) and had 5 failed Embryo Transfers. I was wondering if vaginal sildenafil would help? I am planning for a natural FET, does vaginal sildenafil has any negative impact on the hormones or ovulation or is it fine to use in a natural cycle? Also I read that a low lining is more a problem in a fresh than in a frozen Embryo Transfer. Is that correct? If yes, I would only do FETs in the future.
    Your help is highly appreciated.
    Best
    Anne

  • Jennifer says:

    Our IVF went to a freeze all cycle (lining 4.75) and the following two frozen embryo transfers were cancelled due to linings of 1.1mm and 2.4 mm respectively. The final cycle, I was on a viagra suppository but not terbutaline. Medically, is there enough of a positive correlation between the viagra suppositories and terbutaline to attempt a fourth cycle with only that variable? Thank you!

    • Geoffrey Sher says:

      Hi Jennifer,

      That degree of lining deficiency is extreme and suggests underlying damage to the endometrium. This is usually due to a variety of factors that you will find discussed in the relevant articles referenced below. I urge you to read these. If there is such an extreme degree of damage to the basal (germinal) endometrium then Viagra/terbutaline will have little if any beneficial effect.

      I recently launched a new, personal medical website…………………….www.DrGeoffreySherIVF.com which (among other interesting content houses a brand new Blog where I regularly post new web-based articles that I writeI suggest that you go to the home page on my website and from there access my Blog. When you get to the home page of my Blog,o find the “search bar”. Type in “IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors”, click, and you will immediately be taken directly to this article.

      I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

      I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

      Geoff Sher

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