Dr. Sher Blog

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Viagra as a Treatment to Thicken Uterine Lining

by Dr. Geoffrey Sher on April 11, 2016

About seventeen years ago, after reporting on the benefit of vaginal Sildenafil (Viagra) for women who had implantation dysfunction due to thin endometrial linings, I was proud to announce the birth of the world’s first “Viagra baby.”  For those of you who aren’t familiar with the use of Viagra in IVF, allow me to provide some context.

It was as far back as 1989 when I first published a study that examined the correlation between the thickness of a woman’s uterine lining (the endometrium), and the subsequent successful implantation of embryos in IVF patients. This study revealed that when the uterine lining measured <8mm in thickness by the day of the “hCG trigger” (in fresh IVF cycles), or at the time of initiating progesterone therapy (in embryo recipient cycles, e.g.  frozen embryo transfers, egg donation-IVF etc.), pregnancy and birth rates were substantially improved. Currently, it is my opinion, that an ideal estrogen-promoted endometrial lining should ideally measure at least 9mm in thickness and that an endometrial lining measuring 8-9mm is “intermediate”. An estrogenic lining of <8mm is in most cases unlikely to yield a viable pregnancy.

A “poor” uterine lining is usually the result of the innermost layer of endometrium (the basal or germinal endometrium from which endometrium grows) not being able to respond to estrogen by propagating an outer, “functional,” layer thick enough  to support optimal embryo implantation and development of a healthy placenta (placentation). The “functional” layer ultimately comprises 2/3 of the full endometrial thickness and is the layer that sheds with menstruation in the event that no pregnancy occurs.

The main causes of a “poor” uterine lining are:

  • Damage to the basal endometrium as a result of either
      1. Inflammation of the endometrium (endometritis) most commonly resulting from infected products left over following abortion, miscarriage or birth
  • Surgical trauma due to traumatic uterine scraping, (i.e. due to an over-aggressive D & C)
  • Insensitivity of the basal endometrium to estrogen due to either
      1. Prolonged, overuse/misuse of clomiphene citrate
      2. Prenatal exposure to diethylstilbestrol (DES). This drug was given to pregnant women in the 1960s to help prevent miscarriage
  • Over-exposure of the uterine lining to ovarian male hormones (mainly testosterone): Older women, women with diminished ovarian reserve (poor responders) and women with polycystic ovarian syndrome -PCOS tend to have raised LH biological activity.. This causes the connective tissue in the ovary (stroma/theca) to overproduce testosterone. The effect can be further exaggerated when certain methods for ovarian stimulation such as agonist (Lupron/Buserelin) “flare” protocols and high dosages of menotropins such as Menopur are used in such cases.
  1. Reduced blood flow to the basal endometrium:

Examples include:

    1. Multiple uterine fibroids – especially when these are present under the endometrium (submucosal)
  1. Uterine adenomyosis (excessive, abnormal invasion of the uterine muscle by endometrial glands).

“The Viagra Connection”

Treatments such as supplementary estrogen therapy, aspirin administration and/or administration of high dosage gonadotropin fertility drugs, aimed at improving endometrial development have all yielded disappointing results.

It was in the 90s that Sildenafil (brand named Viagra) was gaining popularity as a treatment for erectile dysfunction. The mechanism by which it acted was through increasing penile blood flow through increasing nitric oxide activity. This prompted me to investigate whether Viagra administered vaginally, might similarly improve uterine blood flow and in the process cause more estrogen to be delivered to the basal endometrium and thereby increase endometrial thickening. We found that when Viagra was administered vaginally it did just that! However oral administration was without any significant benefit in this regard.  We enlisted the services of a compound pharmacy to produce vaginal Viagra suppositories. Initially, four (4) women with chronic histories of poor endometrial development and failure to conceive following several advanced fertility treatments were evaluated for a period of 4-6 weeks and then underwent IVF with concomitant Viagra therapy. Viagra suppositories were administered four times daily for 8-11 days and were discontinued 5-7 days prior to embryo transfer in all cases.

Our findings clearly demonstrated that vaginal Viagra produced a rapid and profound improvement in uterine blood flow and that was followed by enhanced endometrial development in all four cases. Three (3) of the four women subsequently conceived. I expanded the trial in 2002 and became the first to report on the administration of vaginal Viagra to 105 women with repeated IVF failure due to persistently thin endometrial linings. All of the women had experienced at least two (2) prior IVF failures attributed to intractably thin uterine linings. About 70% of these women responded to treatment with Viagra suppositories with a marked improvement in endometrial thickness. 45% achieved live births following a single cycle of IVF treatment with Viagra The miscarriage rate was 9%. None of the women who had failed to show an improvement in endometrial thickness following Viagra treatment achieved viable pregnancies.

Following vaginal administration, Viagra is rapidly absorbed and quickly reaches the uterine blood system in high concentrations. Thereupon it dilutes out as it is absorbed into the systemic circulation. This phenomenon probably explains why treatment is virtually devoid of systemic side effects

Since the introduction of this form of treatment, thousands of women with thin uterine linings have been reported to be treated, and many have gone on to have babies after repeated prior IVF failure.

It is important to recognize that Viagra will NOT be effective in improving endometrial thickness in all cases. In fact, about one third of women treated fail to show any improvement. This is because in certain cases of thin uterine linings, the basal endometrium will have been permanently damaged and left unresponsive to estrogen. This happens in cases of severe endometrial damage due mainly to post-pregnancy endometritis (inflammation), chronic granulomatous inflammation due to uterine tuberculosis (hardly ever seen in the United States) or following extensive surgical injury to the basal endometrium (as sometimes occurs following over-zealous D&C’s).

To be effective, Viagra must be administered vaginally. It is NOT effective when taken orally. We prescribe 20mg vaginal suppositories to be inserted four times per day. Treatment is commenced soon after menstruation ceases and is continued until the day of the “hCG trigger.”  While ideally the treatment should be sustained throughout the first half of the cycle, most women will respond within 48-72 hours. For this reason, Viagra can be used to “rescue” a poor lining after the cycle has already started, provided that there is enough time remaining prior to ovulation, egg retrieval or progesterone administration.

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  • Aditi - July 18, 2018 reply

    Hello Doctor,
    I have been TTC for over 4 years now. I’ve gone through 8 IUIs and a tubal canulation for a blocked tube. I moved on to IVF. After 2 failed IVFs, got success in the 3rd one but resulted in a MMC due to a chromosal disorder. I had to undergo a D&C in December ‘17. I have an AMH of less than 1. But I have always had a good lining. DH and I decided to try another cycle with PGS but since I don’t produce too many good eggs we managed to get 1 day 6 blasto so we decided to freeze the same and moved on to donor eggs. We have 4 embryos frozen with the donor egg. I was to go through a transfer this cycle but for the first time my lining wasn’t responding and remained between 7-8mm. I was put on estradiol valerate 2mg x 2-2, sildenafil 25 x 1-1 and Oestrogel cream once a day. But this did not help and my Doctor said that my lining looked hazy. She has suggested skipping this cycle as this this could be a one off situation as my lining has always been good. If not then they suggest doing a biopsy to check a possible TB infection. Do you think this could be a one off situation? I’m off valest and duphaston since 5 days but my cycle hasn’t started as yet. My cycles are not longer than 1-2 days now. Also, the viagara for insertion has caused me a bad rash which had subsided with local application of betadine but has now reocurred. Would I need some oral medication as well? Thank you so much.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 18, 2018 reply

    I am doubtful that the “hazy uterine lining is an issue. Your diminished ovariann reserve, in my opinion might require a careful review of the protocol used for ovarian stimulation and the reaction to Viagra vaginally raises a question as to how the product was pharmaceutically compounded for use.

    Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
    It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
    1. Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
    2. Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
    We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
    3. The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
    4. Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
    a. A“ thin uterine lining”
    b. A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
    c. Immunologic implantation dysfunction (IID)
    d. Endocrine/molecular endometrial receptivity issues
    Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
    • The Fundamental Requirements for Achieving Optimal IVF Success
    • Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
    • Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Blastocyst Embryo Transfers should be the Standard of Care in IVF
    • IVF: How Many Attempts should be considered before Stopping?
    • “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
    • IVF Failure and Implantation Dysfunction:
    • The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
    • Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
    • Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
    • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
    • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
    • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
    • Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
    • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF?
    • The Role of Nutritional Supplements in Preparing for IVF

    If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .

    *FYI
    The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoffrey Sher MD

  • Lya - June 25, 2018 reply

    kind doctor,
    I am a 44 year old Italian woman.
    I’m about to do my second criotransfer for ovodonation. I have endometrial growth problems, my endometrium never exceeds 6.5 mm.
    I tested Sildenafil 50 in a previous cycle and passed from 6 to 8 mm in just 2-3 days. The medical center that follows me is against use of Sildenafil and I do not respond very well to estrogen therapy. I will try to convince my gynecologist to use Viagra with me, I wanted to ask you if it can cause damage to the embryo and when it should be interrupted.
    thank you so much!
    Lya

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 26, 2018 reply

    Viagra will not damage the embryo or cause serious side effects when administered vaginally at the correct dosage.
    It was as far back as 1989, when I first published a study that examined the correlation between the thickness of a woman’s uterine lining (the endometrium), and the subsequent successful implantation of embryos in IVF patients. This study revealed that when the uterine lining measured <8mm in thickness by the day of the “hCG trigger” (in fresh IVF cycles), or at the time of initiating progesterone therapy (in embryo recipient cycles, e.g. frozen embryo transfers-FET, egg donation-IVF etc.) , pregnancy and birth rates were substantially improved. Currently, it is my opinion, that an ideal estrogen-promoted endometrial lining should ideally measure at least 9mm in thickness and that an endometrial lining measuring 8-9mm is “intermediate”. An estrogenic lining of <8mm is in most cases unlikely to yield a viable pregnancy.

    A “poor” uterine lining is usually the result of the innermost layer of endometrium (the basal or germinal endometrium from which endometrium grows) ) not being able to respond to estrogen by propagating an outer, “functional” layer thick enough to support optimal embryo implantation and development of a healthy placenta (placentation). The “functional” layer ultimately comprises 2/3 of the full endometrial thickness and is the layer that sheds with menstruation in the event that no pregnancy occurs.

    The main causes of a “poor” uterine lining are:

    1. Damage to the basal endometrium as a result of:
    a. Inflammation of the endometrium (endometritis) most commonly resulting from infected products left over following abortion, miscarriage or birth
    b. Surgical trauma due to traumatic uterine scraping, (i.e. due to an over-aggressive D & C)
    2. Insensitivity of the basal endometrium to estrogen due to:
    a. Prolonged , over-use/misuse of clomiphene citrate
    b. Prenatal exposure to diethylstilbestrol (DES). This is a drug that was given to pregnant women in the 1960’s to help prevent miscarriage
    3. Over-exposure of the uterine lining to ovarian male hormones (mainly testosterone): Older women, women with diminished ovarian reserve (poor responders) and women with polycystic ovarian syndrome -PCOS tend to have raised LH biological activity.. This causes the connective tissue in the ovary (stroma/theca) to overproduce testosterone. The effect can be further exaggerated when certain methods for ovarian stimulation such as agonist (Lupron/Buserelin) “flare” protocols and high dosages of menotropins such as Menopur are used in such cases.
    4. Reduced blood flow to the basal endometrium:
    Examples include;
    a. Multiple uterine fibroids - especially when these are present under the endometrium (submucosal)
    b. Uterine adenomyosis (excessive, abnormal invasion of the uterine muscle by endometrial glands).

    “The Viagra Connection”

    Eighteen years ago years ago, after reporting on the benefit of vaginal Sildenafil (Viagra) for to women who had implantation dysfunction due to thin endometrial linings I was proud to announce the birth of the world’s first “Viagra baby.” Since the introduction of this form of treatment, thousands of women with thin uterine linings have been reported treated and many have gone on to have babies after repeated prior IVF failure.

    For those of you who aren’t familiar with the use of Viagra in IVF, allow me to provide some context. It was in the 90’s that Sildenafil (brand named Viagra) started gaining popularity as a treatment for erectile dysfunction. The mechanism by which it acted was through increasing penile blood flow through increasing nitric oxide activity. This prompted me to investigate whether Viagra administered vaginally, might similarly improve uterine blood flow and in the process cause more estrogen to be delivered to the basal endometrium and thereby increase endometrial thickening. We found that when Viagra was administered vaginally it did just that! However oral administration was without any significant benefit in this regard. We enlisted the services of a compound pharmacy to produce vaginal Viagra suppositories. Initially, four (4) women with chronic histories of poor endometrial development and failure to conceive following several advanced fertility treatments were evaluated for a period of 4-6 weeks and then underwent IVF with concomitant Viagra therapy. Viagra suppositories were administered four times daily for 8-11 days and were discontinued 5-7 days prior to embryo transfer in all cases.

    Our findings clearly demonstrated that vaginal Viagra produced a rapid and profound improvement in uterine blood flow and that was followed by enhanced endometrial development in all four cases. Three (3) of the four women subsequently conceived. I expanded the trial in 2002 and became the first to report on the administration of vaginal Viagra to 105 women with repeated IVF failure due to persistently thin endometrial linings. All of the women had experienced at least two (2) prior IVF failures attributed to intractably thin uterine linings. About 70% of these women responded to treatment with Viagra suppositories with a marked improvement in endometrial thickness. Forty five percent (45%) achieved live births following a single cycle of IVF treatment with Viagra The miscarriage rate was 9%. None of the women who had failed to show an improvement in endometrial thickness following Viagra treatment achieved viable pregnancies.

    Following vaginal administration, Viagra is rapidly absorbed and quickly reaches the uterine blood system in high concentrations. Thereupon it dilutes out as it is absorbed into the systemic circulation. This probably explains why treatment is virtually devoid of systemic side effects

    It is important to recognize that Viagra will NOT be effective in improving endometrial thickness in all cases. In fact, about 30%-40% of women treated fail to show any improvement. This is because in certain cases of thin uterine linings, the basal endometrium will have been permanently damaged and left unresponsive to estrogen. This happens in cases of severe endometrial damage due mainly to post-pregnancy endometritis (inflammation), chronic granulomatous inflammation due to uterine tuberculosis (hardly ever seen in the United States) and following extensive surgical injury to the basal endometrium (as sometimes occurs following over-zealous D&C’s).

    Combining vaginal Viagra Therapy with oral Terbutaline;
    In my practice I sometimes recommend combining Viagra administration with 5mg of oral terbutaline. The Viagra relaxes the muscle walls of uterine spiral arteries that feed the basal (germinal) layer of the endometrium while Terbutaline, relaxes the uterine muscle through which these spiral arteries pass. The combination of these two medications interacts synergistically to maximally enhance blood flow through the uterus, thereby improving estrogen delivery to the endometrial lining. The only drawback in using Terbutaline is that some women experience 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 heartbeat.
    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 endometrial inflammation (endometritis) that sometimes occurs post abortally or following infected vaginal and/or cesarean delivery.

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

    To be effective, Viagra must be administered vaginally. It is NOT effective when taken orally. We prescribe 20mg vaginal suppositories to be inserted four times per day. Treatment is commenced soon after menstruation ceases and is continued until the day of the “hCG trigger.” While ideally the treatment should be sustained throughout the first half of the cycle, most women will respond within 48-72 hours. For this reason, Viagra can be used to “rescue” a poor lining after the cycle has already started, provided that there is enough time remaining prior to ovulation, egg retrieval or progesterone administration.

    .
    If you are interested in my advice or medical services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
    Also, my book, “In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoffrey Sher MD

    Lya - June 27, 2018 reply

    thanks dr. Sher
    sorry, I’ll ask you another question.
    I spoke to the center that follows me today and they believe that viagra causes a thickness of the endometrium due to oedema and not normal growth! and they believe that viagra can create small internal hemorrhages … is it possible?
    Regards,
    Lya

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 27, 2018 reply

    In my opinion they are off the mark!

    Geoff Sher

    Lya - June 27, 2018

    Thank you very much! thanks for your time.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 28, 2018

    You are welcome!

    Geoff Sher

    Lya - July 5, 2018

    Dear Dr. Sher,
    I might ask you another question: the day of ovulation or the day when progesterone begins, the use of sildenafil should be discontinued. I wondered if in the five days that are missing to reach the transfer, the thickness reached with Sildenafil can be lost. Can the endometrial thickness be reduced as soon as the use of sildenafil is interrupted?
    thank you very much again!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 5, 2018

    No…not at all!

    Geoff Sher

  • IHL - May 17, 2018 reply

    Dear Dr. Sher,
    I have been treated for PCO with Diane for 15 years. I am now 40 years old and my husband and I have been trying for a baby for 5months.
    I stopped the pill and my PCO came back. I didn’t have an ovulation and my lining was thin (3mm). My doctor started me on the Clomifen 50mg and I had a normal ovulation but the lining stayed thin.
    All other values are fine: No anatomic anomalies, hormone levels ok.
    What do you recommend? Trying with viagra pessaries? Estrogen orally and/or vaginally? Goind straight to IVF? Anything else I could do?
    Warm regards

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 17, 2018 reply

    In my opinion, the chance of success using clomiphene in women of your age is dismal (<2% per cycle of treatment). You really need IVF.

    The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically "incompetent" (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
    While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
    I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
    Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
    • A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
    • Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
    • Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
    • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Blastocyst Embryo Transfers Should be the Standard of Care in IVF
    • Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
    • Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • PGS in IVF: Are Some Chromosomally Abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
    • PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • The Role of Nutritional Supplements in Preparing for IVF
    • Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
    • IVF Egg Donation: A Comprehensive Overview

    If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .

    *FYI
    The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

  • Isabel - May 16, 2018 reply

    Could you please be so kind to give the detailed formulation (compound) of the recommended viagra suppositories so a pharmacy can prepare them?
    Thank you
    Isabel

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 16, 2018 reply

    Sorry!
    You would need to have your pharmacist contact a pharmacy that does such compounding, for the information. I suggest MDRx Pharmacy in S. California.

    Geoff Sher

  • Kate Angell - May 7, 2018 reply

    I have been on your suggested viagra treatment (20mg 4 x daily) for just on 10 days along with estrogen tablets and patches and my lining is only about 6.5, last month it got to 7mm (with no viagra). My doctor has suggested continuing the treatment for another week and re-scanning.
    I have tried calling Julie to make an appointment. Do you think another week is worthwhile??
    Any other suggestions??
    Thank you in advance, Kate Angell

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 8, 2018 reply

    Worth trying but I do not think it will help.

    Geoff Sher

  • Patience - April 27, 2018 reply

    Hi Dr Sher, thanks for this write up. I am having an FET next month and it’s a one time chance for us as we only have 1 viable embryo. It is my first transfer so i can’t say if i have bad lining or not but i want to do all i can to prepare my lining. I have asked for viagra and will be using it for 8 days.

    Is it ok for me to use viagra without an history of thin lining? Will it harm me if I don’t really need it but using it just to ensure my lining is thick and tripled line?

    Thanks and God bless!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 27, 2018 reply

    No harm…but unlikely it would help if you already produce a good lining.

    Geoff Sher

  • Kate Angell - April 11, 2018 reply

    Dear Dr Sher, I have had endometriosis, fibroids and Ashermans Syndrome. I had two surgeries to correct the Ashermans and actually got pregnant for the first and only time after that lost at 11 weeks due to Edwards Syndrome), so ideally my lining has not been permanently damaged.
    Due to my age we are now trying Donor eggs but my lining is not getting beyond 7.5 to 8.5. I recently had PRP treatment to help improve the lining, but after estrogren the first scan was 7mm and a week later no change still 7mm (triple layer). I decided to cancel the cycle and try to achieve a better lining next cycle.
    My doctor has suggested Viagra, and after coming across your video I would love your opinion. With my history, and recent PRP treatment do you think adding Viagra will be successful? My estrogen reading from my blood test was 2585, so absorption is occurring but not conversion.
    Getting older and running out of time, but a gestational carrier is unfortunately not an option. Thank you
    PS – I am also on a lot of immunology treatment, Clexane, Prednisolone, Aspirin, Plaquenil, Neuprogen, Metformin and Trental – the last two were meant to help the lining, but I don’t think they have made a difference. I have also used Intralipids the last few transfers (with the successful pregnancy, but they are suggesting IVIG now)

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 11, 2018 reply

    It is certainly worth trying Viagra with estrogen supplementation.

    Geoff Sher

  • Liz - April 6, 2018 reply

    My daughter had IUGR. She was conceived naturally. I’ve been trying for my second for 2 years. How long do you stay on viagra? Do you take it after transfer?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 6, 2018 reply

    It was as far back as 1989, when I first published a study that examined the correlation between the thickness of a woman’s uterine lining (the endometrium), and the subsequent successful implantation of embryos in IVF patients. This study revealed that when the uterine lining measured <8mm in thickness by the day of the “hCG trigger” (in fresh IVF cycles), or at the time of initiating progesterone therapy (in embryo recipient cycles, e.g. frozen embryo transfers-FET, egg donation-IVF etc.) , pregnancy and birth rates were substantially improved. Currently, it is my opinion, that an ideal estrogen-promoted endometrial lining should ideally measure at least 9mm in thickness and that an endometrial lining measuring 8-9mm is “intermediate”. An estrogenic lining of <8mm is in most cases unlikely to yield a viable pregnancy.

    A “poor” uterine lining is usually the result of the innermost layer of endometrium (the basal or germinal endometrium from which endometrium grows) ) not being able to respond to estrogen by propagating an outer, “functional” layer thick enough to support optimal embryo implantation and development of a healthy placenta (placentation). The “functional” layer ultimately comprises 2/3 of the full endometrial thickness and is the layer that sheds with menstruation in the event that no pregnancy occurs.

    The main causes of a “poor” uterine lining are:

    1. Damage to the basal endometrium as a result of:
    a. Inflammation of the endometrium (endometritis) most commonly resulting from infected products left over following abortion, miscarriage or birth
    b. Surgical trauma due to traumatic uterine scraping, (i.e. due to an over-aggressive D & C)
    2. Insensitivity of the basal endometrium to estrogen due to:
    a. Prolonged , over-use/misuse of clomiphene citrate
    b. Prenatal exposure to diethylstilbestrol (DES). This is a drug that was given to pregnant women in the 1960’s to help prevent miscarriage
    3. Over-exposure of the uterine lining to ovarian male hormones (mainly testosterone): Older women, women with diminished ovarian reserve (poor responders) and women with polycystic ovarian syndrome -PCOS tend to have raised LH biological activity.. This causes the connective tissue in the ovary (stroma/theca) to overproduce testosterone. The effect can be further exaggerated when certain methods for ovarian stimulation such as agonist (Lupron/Buserelin) “flare” protocols and high dosages of menotropins such as Menopur are used in such cases.
    4. Reduced blood flow to the basal endometrium:
    Examples include;
    a. Multiple uterine fibroids - especially when these are present under the endometrium (submucosal)
    b. Uterine adenomyosis (excessive, abnormal invasion of the uterine muscle by endometrial glands).

    “The Viagra Connection”

    Eighteen years ago years ago, after reporting on the benefit of vaginal Sildenafil (Viagra) for to women who had implantation dysfunction due to thin endometrial linings I was proud to announce the birth of the world’s first “Viagra baby.” Since the introduction of this form of treatment, thousands of women with thin uterine linings have been reported treated and many have gone on to have babies after repeated prior IVF failure.

    For those of you who aren’t familiar with the use of Viagra in IVF, allow me to provide some context. It was in the 90’s that Sildenafil (brand named Viagra) started gaining popularity as a treatment for erectile dysfunction. The mechanism by which it acted was through increasing penile blood flow through increasing nitric oxide activity. This prompted me to investigate whether Viagra administered vaginally, might similarly improve uterine blood flow and in the process cause more estrogen to be delivered to the basal endometrium and thereby increase endometrial thickening. We found that when Viagra was administered vaginally it did just that! However oral administration was without any significant benefit in this regard. We enlisted the services of a compound pharmacy to produce vaginal Viagra suppositories. Initially, four (4) women with chronic histories of poor endometrial development and failure to conceive following several advanced fertility treatments were evaluated for a period of 4-6 weeks and then underwent IVF with concomitant Viagra therapy. Viagra suppositories were administered four times daily for 8-11 days and were discontinued 5-7 days prior to embryo transfer in all cases.

    Our findings clearly demonstrated that vaginal Viagra produced a rapid and profound improvement in uterine blood flow and that was followed by enhanced endometrial development in all four cases. Three (3) of the four women subsequently conceived. I expanded the trial in 2002 and became the first to report on the administration of vaginal Viagra to 105 women with repeated IVF failure due to persistently thin endometrial linings. All of the women had experienced at least two (2) prior IVF failures attributed to intractably thin uterine linings. About 70% of these women responded to treatment with Viagra suppositories with a marked improvement in endometrial thickness. Forty five percent (45%) achieved live births following a single cycle of IVF treatment with Viagra The miscarriage rate was 9%. None of the women who had failed to show an improvement in endometrial thickness following Viagra treatment achieved viable pregnancies.

    Following vaginal administration, Viagra is rapidly absorbed and quickly reaches the uterine blood system in high concentrations. Thereupon it dilutes out as it is absorbed into the systemic circulation. This probably explains why treatment is virtually devoid of systemic side effects

    It is important to recognize that Viagra will NOT be effective in improving endometrial thickness in all cases. In fact, about 30%-40% of women treated fail to show any improvement. This is because in certain cases of thin uterine linings, the basal endometrium will have been permanently damaged and left unresponsive to estrogen. This happens in cases of severe endometrial damage due mainly to post-pregnancy endometritis (inflammation), chronic granulomatous inflammation due to uterine tuberculosis (hardly ever seen in the United States) and following extensive surgical injury to the basal endometrium (as sometimes occurs following over-zealous D&C’s).

    Combining vaginal Viagra Therapy with oral Terbutaline;
    In my practice I sometimes recommend combining Viagra administration with 5mg of oral terbutaline. The Viagra relaxes the muscle walls of uterine spiral arteries that feed the basal (germinal) layer of the endometrium while Terbutaline, relaxes the uterine muscle through which these spiral arteries pass. The combination of these two medications interacts synergistically to maximally enhance blood flow through the uterus, thereby improving estrogen delivery to the endometrial lining. The only drawback in using Terbutaline is that some women experience 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 heartbeat.
    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 endometrial inflammation (endometritis) that sometimes occurs post abortally or following infected vaginal and/or cesarean delivery.
    Viagra therapy has proven to be a god send to thousands of woman who because of a thin uterine lining would otherwise never have been able to successfully complete the journey “from infertility to family”.

    To be effective, Viagra must be administered vaginally. It is NOT effective when taken orally. We prescribe 20mg vaginal suppositories to be inserted four times per day. Treatment is commenced soon after menstruation ceases and is continued until the day of the “hCG trigger.” While ideally the treatment should be sustained throughout the first half of the cycle, most women will respond within 48-72 hours. For this reason, Viagra can be used to “rescue” a poor lining after the cycle has already started, provided that there is enough time remaining prior to ovulation, egg retrieval or progesterone administration.

    Geoff Sher

    .

  • Liz Schulz - April 6, 2018 reply

    My daughter had IUGR. She was conceived naturally. I’ve been trying for my second for 2 years. How long do you stay on viagra? Do you take it after transfer?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 6, 2018 reply

    Only taken until the hCG trigger with fresh ET or the initiation of progesterone with embryo recipient cycles (e.g. FET, egg donation, gestational surrogacy or embryo donation).

    Geoff Sher

  • Erika - February 16, 2018 reply

    I am be treated for recurrent miscarriage (3), likely due to poor blood flow post uterine artery embolization for a uterine fibroid 8 years ago. My RE has me taking 1 viagra suppository for 10 nights AFTER ovulation. Do you think this will be helpful, or that I should be taking it before ovulation? Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 16, 2018 reply

    hard to say because embolization of fibroids can also compromise blood flow to the uterine lining.

    Good luck!

    Geoff sher

  • Paty - February 1, 2018 reply

    Hello,
    I’m being treated in Houston, TX. My FS doctor prescribed me vaginal viagra (2x25mg daily).
    I’m trying to find a pharmacy that can compound the viagra in vaginal suppositories. Could you please advice me where can I ordered them?
    Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2018 reply

    Contact MDRx in Simi valley, CA (go to Google).

    Geoff Sher

    Paty - February 2, 2018 reply

    Thank you so much for your response. I will contact them.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2018 reply

    You are most welcome!

    Geoff Sher

  • Sarah - November 3, 2017 reply

    Can I use 80 mg once a day instead of 20 mg four times a day?
    Thank you !

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - November 3, 2017 reply

    I would advise against this!

    Geoff Sher

  • Sarah - November 2, 2017 reply

    Dear Dr. Sher!
    Is it effective to use 80 mg Viagra vaginally once a day instead of 20mg 4 times a day? Thank you!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - November 2, 2017 reply

    I doubt it would be as effective Sarah!

    Geoff Sher

  • rachel - September 28, 2017 reply

    Hi your work is amazing!
    Just a quick question can I take normal Viagra tablets and use them as a suppository? The ingredients and it seems the same. It is hard to get suppositories in my country.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - September 28, 2017 reply

    Not nearly as effective as compounded vaginal Viagra!

    Geoff Sher

  • Zuza - August 20, 2017 reply

    Hello Dr Sher,
    While taking Viagra “four times per day” is it important to take it equally every 6 hours? – or is it OK to just take it before bed, then in the morning with the other two times spread during the day?
    Thank you,
    Zuza

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 20, 2017 reply

    The latter is in fact preferred!

    Geoff Sher

    Zuza - August 21, 2017 reply

    Thank you!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 21, 2017 reply

    You are welcome!

    Geoff Sher

  • Anabel - July 18, 2017 reply

    I tried the vaginal viagra with no luck. Any other suggestions?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 18, 2017 reply

    I would need much more information to be able to respond informatively!

    Geoff Sher

  • Jenny - May 26, 2017 reply

    Hello,

    I was wondering if vaginal Viagra would be effective, even without IUI or IVF. I just finished my 3rd IUI, and it appears that everything is completely normal (antral follicle count, sperm count, all blood tests), aside from my endometrial lining, which has been persistently thin. On the day of HCG trigger over my last 3 cycles, it was 6.6mm the first month, 5.9mm the second, and 6.7mm the third. If my upcoming hysteroscopy rules out any uterine damage from fibroids, scarring, etc (I am anticipating it will, as I’ve never experienced any problems up to this point), would it make sense to try Viagra therapy, without any further fertility treatments?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 27, 2017 reply

    Yes! It could be effective without being used in conjunction with IVF.

    About seventeen years ago, after reporting on the benefit of vaginal Sildenafil (Viagra) for to women who had implantation dysfunction due to thin endometrial linings I was proud to announce the birth of the world’s first “Viagra baby.” For those of you who aren’t familiar with the use of Viagra in IVF, allow me to provide some context.

    It was as far back as 1989, when I first published a study that examined the correlation between the thickness of a woman’s uterine lining (the endometrium), and the subsequent successful implantation of embryos in IVF patients. This study revealed that when the uterine lining measured <8mm in thickness by the day of the “hCG trigger” (in fresh IVF cycles), or at the time of initiating progesterone therapy (in embryo recipient cycles, e.g. frozen embryo transfers, egg donation-IVF etc.) , pregnancy and birth rates were substantially improved. Currently, it is my opinion, that an ideal estrogen-promoted endometrial lining should ideally measure at least 9mm in thickness and that an endometrial lining measuring 8-9mm is “intermediate”. An estrogenic lining of <8mm is in most cases unlikely to yield a viable pregnancy.

    A “poor” uterine lining is usually the result of the innermost layer of endometrium (the basal or germinal endometrium from which endometrium grows) ) not being able to respond to estrogen by propagating an outer, “functional” layer thick enough to support optimal embryo implantation and development of a healthy placenta (placentation). The “functional” layer ultimately comprises 2/3 of the full endometrial thickness and is the layer that sheds with menstruation in the event that no pregnancy occurs.

    The main causes of a “poor” uterine lining are:

    1. Damage to the basal endometrium as a result of:
    a. Inflammation of the endometrium (endometritis) most commonly resulting from infected products left over following abortion, miscarriage or birth
    b. Surgical trauma due to traumatic uterine scraping, (i.e. due to an over-aggressive D & C)
    2. Insensitivity of the basal endometrium to estrogen due to:
    a. Prolonged , over-use/misuse of clomiphene citrate
    b. Prenatal exposure to diethylstilbestrol (DES). This is a drug that was given to pregnant women in the 1960’s to help prevent miscarriage
    3. Over-exposure of the uterine lining to ovarian male hormones (mainly testosterone): Older women, women with diminished ovarian reserve (poor responders) and women with polycystic ovarian syndrome -PCOS tend to have raised LH biological activity.. This causes the connective tissue in the ovary (stroma/theca) to overproduce testosterone. The effect can be further exaggerated when certain methods for ovarian stimulation such as agonist (Lupron/Buserelin) “flare” protocols and high dosages of menotropins such as Menopur are used in such cases.
    4. Reduced blood flow to the basal endometrium:
    Examples include;
    a. Multiple uterine fibroids - especially when these are present under the endometrium (submucosal)
    b. Uterine adenomyosis (excessive, abnormal invasion of the uterine muscle by endometrial glands).

    “The Viagra Connection”

    Treatments such supplementary estrogen therapy, aspirin administration and/or administration of high dosage gonadotropin fertility drugs, aimed at improving endometrial development have all yielded disappointing results.

    It was in the 90’s that Sildenafil (brand named Viagra) was gaining popularity as a treatment for erectile dysfunction. The mechanism by which it acted was through increasing penile blood flow through increasing nitric oxide activity. This prompted me to investigate whether Viagra administered vaginally, might similarly improve uterine blood flow and in the process cause more estrogen to be delivered to the basal endometrium and thereby increase endometrial thickening. We found that when Viagra was administered vaginally it did just that! However oral administration was without any significant benefit in this regard. We enlisted the services of a compound pharmacy to produce vaginal Viagra suppositories. Initially, four (4) women with chronic histories of poor endometrial development and failure to conceive following several advanced fertility treatments were evaluated for a period of 4-6 weeks and then underwent IVF with concomitant Viagra therapy. Viagra suppositories were administered four times daily for 8-11 days and were discontinued 5-7 days prior to embryo transfer in all cases.

    Our findings clearly demonstrated that vaginal Viagra produced a rapid and profound improvement in uterine blood flow and that was followed by enhanced endometrial development in all four cases. Three (3) of the four women subsequently conceived. . I expanded the trial in 2002 and became the first to report on the administration of vaginal Viagra to 105 women with repeated IVF failure due to persistently thin endometrial linings. All of the women had experienced at least two (2) prior IVF failures attributed to intractably thin uterine linings. About 70% of these women responded to treatment with Viagra suppositories with a marked improvement in endometrial thickness. Forty five percent (45%) achieved live births following a single cycle of IVF treatment with Viagra The miscarriage rate was 9%. None of the women who had failed to show an improvement in endometrial thickness following Viagra treatment achieved viable pregnancies.
    Following vaginal administration, Viagra is rapidly absorbed and quickly reaches the uterine blood system in high concentrations. Thereupon it dilutes out as it is absorbed into the systemic circulation. This probably explains why treatment is virtually devoid of systemic side effects

    Since the introduction of this form of treatment, thousands of women with thin uterine linings have been reported treated and many have gone on to have babies after repeated prior IVF failure.

    It is important to recognize that Viagra will NOT be effective in improving endometrial thickness in all cases. In fact, about one third of women treated fail to show any improvement. This is because in certain cases of thin uterine linings, the basal endometrium will have been permanently damaged and left unresponsive to estrogen. This happens in cases of severe endometrial damage due mainly to post-pregnancy endometritis (inflammation), chronic granulomatous inflammation due to uterine tuberculosis (hardly ever seen in the United States) and following extensive surgical injury to the basal endometrium (as sometimes occurs following over-zealous D&C’s).

    To be effective, Viagra must be administered vaginally. It is NOT effective when taken orally. We prescribe 20mg vaginal suppositories to be inserted four times per day. Treatment is commenced soon after menstruation ceases and is continued until the day of the “hCG trigger.” While ideally the treatment should be sustained throughout the first half of the cycle, most women will respond within 48-72 hours. For this reason, Viagra can be used to “rescue” a poor lining after the cycle has already started, provided that there is enough time remaining prior to ovulation, egg retrieval or progesterone administration.

    .

    Good luck!

    Geoff Sher

    Jenny - May 27, 2017 reply

    Great to hear! I truly appreciate your response!

    Just out of curiosity, in your experience, how common is a persistently thin uterine lining the main cause of infertility for women? There seems to be so much emphasis on testing for and treating ovulation problems, but not a lot focusing on the uterus itself. Is this because uterine lining issues are uncommon?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 28, 2017 reply

    A persistently thin lining (<8mm) is very commonly associated with absent or dysfunctional implantation, presenting as "infertility, early pregnancy loss" and sometimes with placental insufficiency with intrauterine growth retardation (IUGR)".

    Geoff Sher

  • Teauna Krajacic - April 26, 2017 reply

    Hello Dr. Sher I’ve heard great things about you! I wish I were closer to you. We are about to start our 3rd and final FET. The two prior were BFN. My doctor is putting me on Viagra as my last cycle was almost canceled because it took me an added 3 weeks just to get to 7.84mm! I am scheduled for a saline sonogram to check my endometrial lining, I suspect I have scarring. My question is, has Viagra therapy been shown to work in women with uterine scarring?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 26, 2017 reply

    It could help but often in such cases it unfortunately does not!

    About seventeen years ago, after reporting on the benefit of vaginal Sildenafil (Viagra) for to women who had implantation dysfunction due to thin endometrial linings I was proud to announce the birth of the world’s first “Viagra baby.” For those of you who aren’t familiar with the use of Viagra in IVF, allow me to provide some context.

    It was as far back as 1989, when I first published a study that examined the correlation between the thickness of a woman’s uterine lining (the endometrium), and the subsequent successful implantation of embryos in IVF patients. This study revealed that when the uterine lining measured <8mm in thickness by the day of the “hCG trigger” (in fresh IVF cycles), or at the time of initiating progesterone therapy (in embryo recipient cycles, e.g. frozen embryo transfers, egg donation-IVF etc.) , pregnancy and birth rates were substantially improved. Currently, it is my opinion, that an ideal estrogen-promoted endometrial lining should ideally measure at least 9mm in thickness and that an endometrial lining measuring 8-9mm is “intermediate”. An estrogenic lining of <8mm is in most cases unlikely to yield a viable pregnancy.

    A “poor” uterine lining is usually the result of the innermost layer of endometrium (the basal or germinal endometrium from which endometrium grows) ) not being able to respond to estrogen by propagating an outer, “functional” layer thick enough to support optimal embryo implantation and development of a healthy placenta (placentation). The “functional” layer ultimately comprises 2/3 of the full endometrial thickness and is the layer that sheds with menstruation in the event that no pregnancy occurs.

    The main causes of a “poor” uterine lining are:

    1. Damage to the basal endometrium as a result of:
    a. Inflammation of the endometrium (endometritis) most commonly resulting from infected products left over following abortion, miscarriage or birth
    b. Surgical trauma due to traumatic uterine scraping, (i.e. due to an over-aggressive D & C)
    2. Insensitivity of the basal endometrium to estrogen due to:
    a. Prolonged , over-use/misuse of clomiphene citrate
    b. Prenatal exposure to diethylstilbestrol (DES). This is a drug that was given to pregnant women in the 1960’s to help prevent miscarriage
    3. Over-exposure of the uterine lining to ovarian male hormones (mainly testosterone): Older women, women with diminished ovarian reserve (poor responders) and women with polycystic ovarian syndrome -PCOS tend to have raised LH biological activity.. This causes the connective tissue in the ovary (stroma/theca) to overproduce testosterone. The effect can be further exaggerated when certain methods for ovarian stimulation such as agonist (Lupron/Buserelin) “flare” protocols and high dosages of menotropins such as Menopur are used in such cases.
    4. Reduced blood flow to the basal endometrium:
    Examples include;
    a. Multiple uterine fibroids - especially when these are present under the endometrium (submucosal)
    b. Uterine adenomyosis (excessive, abnormal invasion of the uterine muscle by endometrial glands).

    “The Viagra Connection”

    Treatments such supplementary estrogen therapy, aspirin administration and/or administration of high dosage gonadotropin fertility drugs, aimed at improving endometrial development have all yielded disappointing results.

    It was in the 90’s that Sildenafil (brand named Viagra) was gaining popularity as a treatment for erectile dysfunction. The mechanism by which it acted was through increasing penile blood flow through increasing nitric oxide activity. This prompted me to investigate whether Viagra administered vaginally, might similarly improve uterine blood flow and in the process cause more estrogen to be delivered to the basal endometrium and thereby increase endometrial thickening. We found that when Viagra was administered vaginally it did just that! However oral administration was without any significant benefit in this regard. We enlisted the services of a compound pharmacy to produce vaginal Viagra suppositories. Initially, four (4) women with chronic histories of poor endometrial development and failure to conceive following several advanced fertility treatments were evaluated for a period of 4-6 weeks and then underwent IVF with concomitant Viagra therapy. Viagra suppositories were administered four times daily for 8-11 days and were discontinued 5-7 days prior to embryo transfer in all cases.

    Our findings clearly demonstrated that vaginal Viagra produced a rapid and profound improvement in uterine blood flow and that was followed by enhanced endometrial development in all four cases. Three (3) of the four women subsequently conceived. . I expanded the trial in 2002 and became the first to report on the administration of vaginal Viagra to 105 women with repeated IVF failure due to persistently thin endometrial linings. All of the women had experienced at least two (2) prior IVF failures attributed to intractably thin uterine linings. About 70% of these women responded to treatment with Viagra suppositories with a marked improvement in endometrial thickness. Forty five percent (45%) achieved live births following a single cycle of IVF treatment with Viagra The miscarriage rate was 9%. None of the women who had failed to show an improvement in endometrial thickness following Viagra treatment achieved viable pregnancies.
    Following vaginal administration, Viagra is rapidly absorbed and quickly reaches the uterine blood system in high concentrations. Thereupon it dilutes out as it is absorbed into the systemic circulation. This probably explains why treatment is virtually devoid of systemic side effects

    Since the introduction of this form of treatment, thousands of women with thin uterine linings have been reported treated and many have gone on to have babies after repeated prior IVF failure.

    It is important to recognize that Viagra will NOT be effective in improving endometrial thickness in all cases. In fact, about one third of women treated fail to show any improvement. This is because in certain cases of thin uterine linings, the basal endometrium will have been permanently damaged and left unresponsive to estrogen. This happens in cases of severe endometrial damage due mainly to post-pregnancy endometritis (inflammation), chronic granulomatous inflammation due to uterine tuberculosis (hardly ever seen in the United States) and following extensive surgical injury to the basal endometrium (as sometimes occurs following over-zealous D&C’s).

    To be effective, Viagra must be administered vaginally. It is NOT effective when taken orally. We prescribe 20mg vaginal suppositories to be inserted four times per day. Treatment is commenced soon after menstruation ceases and is continued until the day of the “hCG trigger.” While ideally the treatment should be sustained throughout the first half of the cycle, most women will respond within 48-72 hours. For this reason, Viagra can be used to “rescue” a poor lining after the cycle has already started, provided that there is enough time remaining prior to ovulation, egg retrieval or progesterone administration.

    Good luck!

    Geoff Sher

  • Clare - February 21, 2017 reply

    Hi Dr. Geoffrey
    I had IUI yesterday my lining was 7mm. Is it safe to use 25mg viagra pessaries at this stage? I am taking 400mg vaginal progesterone pessaries as prescribed by my doctor.
    Many thanks

    Clare

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 21, 2017 reply

    There is no benefit stating Viagra at this stage. It is far too late.

    Geoff Sher

  • Zenab - December 11, 2016 reply

    Dear doctor,
    I am currently undergoing my first I’ve cycle and have been prescribed vaginal alivher for 14 days post 2 day embryo transfer. I am on day 6 of alivher – inserted 3 times a day. I am also using crinone gel twice a day. The problem is that the tablets Are getting collected down there and Iv tried washing them out. I’m also getting A burning sensation. What should I do?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 11, 2016 reply

    Sildenafil (Viagra.Alivher) needs to be compounded for optimal vaginal absorbtion. The tablets are not adequate to improve uterine blood flow and thickening of the endometrium. Besides, in my opinion, to be effective the administration of vaginal sildenafil needs to be done prior to progesterone (e.g Crinone)…i.e. before ovulation and before progesterone administration.

    Geoff Sher

    Zenab - December 13, 2016 reply

    Thank you so much for your reply Doctor. Given my circumstances, I guess I have no choice right now but to proceed on my current doctor’s recommendations and hope for the best. I do wish I had looked you up sooner.
    Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 13, 2016 reply

    Good luck and merry Xmas!

    Geoff Sher

  • Sharon - November 8, 2016 reply

    Hi Dr Sher, I deal with a ‘thin lining’ and have tired everything available but to no avail, my lining is always about 7mm at the time of trigger or progesterone. I have frozen embroys so due to have another FET soon and my lining does not get above 6mm on estrogen alone so I will be on a low dose stim as I respond a little better that way. My question is, do you think 150iu of Gonal F, adding in 75iu of Menopur from CD7 plus 2mg of estrofem is a good protocol? I have heard Menopur is more ‘lining friendly’ and the one time I used Menopur with Gonal F I had my best lining yet although this was a fresh cycle and I was on a much higher dose. Would love to hear your thoughts on Menopur! Thank you 🙂

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - November 8, 2016 reply

    No Sharon, I do not believe this would help.

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691
     800-780-7437

    Geoff Sher

    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.

    Sharon - November 8, 2016 reply

    Thanks for your reply Dr. Sher! I am due to start my meds next week!! Out of interest can I ask why you do not believe this will help as my lining does respond better to a low dose stim?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - November 8, 2016 reply

    We would need to talk Sharon!

    Geoff Sher

    Sharon - November 9, 2016

    Sorry Dr. Sher as I am staring my meds on Monday I will not have time to set up a consultation with you so I am very nervous now 🙁 my clinic has me on the low dose of Gonal F/Menopur with 2mg estrofem added from CD7 as this is how my lining responds best on a fresh cycle and I do not respond to estrogen pills alone so they have me on a much lower dose then a fresh cycle with the hope my lining will be >8mm this time. Would I be best just doing Gonal F on its own with the estrofem? Apologies for all the questions but this will be our 7th transfer (plus we had 4 transfers cancelled due to poor lining) so I am very worried and nervous 🙁

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - November 9, 2016

    Sorry Sharon,

    I cannot interject myself into a cycle where you are being treated by another doctor.

    Geoff Sher

  • Ashley - August 16, 2016 reply

    Hello,
    I am currently being treated with estrace tables vaginally BID, but my lining remains chronically thin. Although my RE does not typically use Viagra to help with lining, he has agreed to prescribe it for this cycle. Do you think that taking it QID from time of trigger shot until I start progesterone will be enough time to rescue my lining? In previous cycles my lining is about 6.5-7 mm at the time of trigger but am hoping to get to 8mm or above.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 16, 2016 reply

    No! It will likely not help unless you have used it for >2 days prior to the b”trigger”.

    Sorry!

    Geoff Sher

    Ashley - August 16, 2016 reply

    Thank you for your prompt response! Given the timing of this cycle and my latest scan, I’m at least 3-5 days pre trigger and have 24 dose available, is it worth taking any doses now either BID/TID/QID? If so, can you make any recommendations for dose schedule and start to see some results?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 16, 2016 reply

    I prescribe 20mg of compounded Viagra suppositories 4 times per day until the hCG trigger.

    Good luck!

    Geoff Sher

    Ashley - August 21, 2016

    Based on your suggestion, I have been taking 20mg QID for 3 days, but my uterus is feeling very tender/crampy. Is this a normal side effect?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 21, 2016

    I do not think it is anything to be concerned about!

    Good luck!

    Geoff Sher

  • Jana Ernoult - August 14, 2016 reply

    Hi, is it possible to get Viagra suppositories shipped to UK
    ? Thank you Jana

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 14, 2016 reply

    I don’t think so, not unless you are being treated in the U.S.A.

    Geoff Sher

    Lowenna - August 27, 2016 reply

    As suppositories are not available in my country, could I use instead a third of a Generic Female Viagra tablet (100mg Sildenafil Citrate) and insert it vaginally?
    many thanks indeed for your work!
    L

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 28, 2016 reply

    It is not nearly as efficient as the compounded product but perhaps it is worth a try.

    Geoff Sher

    Lowenna - August 28, 2016

    thank you very much indeed for your fast reply!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - August 29, 2016

    You are very welcome

    Geoff Sher

  • alicia - July 18, 2016 reply

    Dr. thanks for listening .
    In my country alone is achieved Viagra pills. tablets 50 mg and 100 mg Pfizer laboratory. These can be used by way of ovules . in my country I can not get viagra in ovules .

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 19, 2016 reply

    So sorry!. I understand.

    Geoff Sher

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