Sildenafil citrate for the management of fetal growth restriction and oligohydramnios

If you experience a sudden loss of hearing, sometimes with ringing in the ears or dizziness, while you are taking sildenafil, call your doctor immediately. If you are taking sildenafil (Viagra) for erectile dysfunction, do not take any more doses of sildenafil (Viagra) or similar medications such as tadalafil (Cialis) or vardenafil (Levitra) until you talk to your doctor. If you are taking sildenafil (Liqrev, Revatio) for PAH, do not stop taking your medication until you talk to your doctor. Call your doctor if you have any unusual problems while you are taking this medication. If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online ( or by phone (1-800-332-1088). Keep this medication in the container it came in, tightly closed, and out of reach of children. Store the tablets at room temperature and away from excess heat and moisture (not in the bathroom). Store the suspension at room temperature or in a refrigerator, but do not freeze it. Dispose of any unused suspension after 60 days.

Keep all medication out of sight and reach of children as many containers are not child-resistant. Place the medication in a safe location – one that is up and away and out of their sight and reach.

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If you experience a sudden loss of hearing, sometimes with ringing in the ears or dizziness, while you are taking sildenafil, call your doctor immediately. If you are taking sildenafil (Viagra) for erectile dysfunction, do not take any more doses of sildenafil (Viagra) or similar medications such as tadalafil (Cialis) or vardenafil (Levitra) until you talk to your doctor. If you are taking sildenafil (Liqrev, Revatio) for PAH, do not stop taking your medication until you talk to your doctor. Call your doctor if you have any unusual problems while you are taking this medication. If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online ( or by phone (1-800-332-1088).

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Keep this medication in the container it came in, tightly closed, and out of reach of children. Store the tablets at room temperature and away from excess heat and moisture (not in the bathroom). Store the suspension at room temperature or in a refrigerator, but do not freeze it. Dispose of any unused suspension after 60 days. Keep all medication out of sight and reach of children as many containers are not child-resistant.

Before taking sildenafil,

Place the medication in a safe location – one that is up and away and out of their sight and reach. Dispose of unneeded medications in a way so that pets, children, and other people cannot take them. Do not flush this medication down the toilet. Talk to your pharmacist about take-back programs in your community. Visit the FDA's Safe Disposal of Medicines website for more information. Dispose of unneeded medications in a way so that pets, children, and other people cannot take them. Do not flush this medication down the toilet. Talk to your pharmacist about take-back programs in your community. Visit the FDA's Safe Disposal of Medicines website for more information. In case of overdose, call the poison control helpline at 1-800-222-1222. Information is also available online at If the victim has collapsed, had a seizure, has trouble breathing, or can't be awakened, immediately call emergency services at 911. Do not let anyone else take your medication.

Ask your pharmacist any questions you have about refilling your prescription. Keep a written list of all of the prescription and nonprescription (over-the-counter) medicines, vitamins, minerals, and dietary supplements you are taking. Bring this list with you each time you visit a doctor or if you are admitted to the hospital. You should carry the list with you in case of emergencies.

• Female-specific studies on sildenafil show mixed results.
• Sildenafil is sometimes used off-label for female libido enhancement.
• Always check for allergies before taking sildenafil citrate tablets.
• Sildenafil may cause vision disturbances in some women.
• Proper hydration can reduce side effects when using sildenafil.
• Combining sildenafil with alcohol can increase risks.
• Be aware of potential interactions with hormonal contraceptives.
• Do not share sildenafil tablets to prevent misuse or overdose.
• Women should report any adverse reactions to their healthcare provider.
• Sildenafil may help with certain conditions like Female Sexual Arousal Disorder.
• Cost of sildenafil for women varies, and insurance may not cover it.
• Follow prescribed instructions precisely to avoid overdose.

Back to Journals » International Journal of Women's Health » Volume 8 Authors Choudhary R , Desai K, Parekh H, Ganla K Published 9 August 2016 Volume 2016:8 Pages 367—372 Editor who approved publication: Professor Elie Al-Chaer Rana Choudhary,1 Kavita Desai,2 Hetal Parekh,3 Kedar Ganla1 1Department of Reproductive Medicine, Ankoor Fertility Clinic, 2Department of Radiology, Dadar Imaging and Diagnostic Centre, 3IVF Department, Hiranandani Hospital, Mumbai, India Abstract: Fetal growth restriction (FGR) and preeclampsia are the major causes of neonatal morbidity and mortality, which affect up to 8% of all pregnancies.

• 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 pathogenesis in FGR is an abnormal trophoblastic invasion leading to compromised uteroplacental circulation. However, in spite of this understanding and identification of high-risk patients, the management options are limited. There are some new studies which have demonstrated the role of sildenafil citrate in improving vasodilatation of small myometrial vessels and therefore improvement in amniotic fluid index, fetal weight, and even uterine and umbilical artery Doppler patterns.

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The umbilical artery diastolic flow improved after 2 weeks of therapy, with no brain-sparing effect in MCA; however, the S/D ratio was >3. Furthermore, ultrasound at 30 weeks showed an AFI of 7.5 and a fetal weight of 1,000 g. The patient also experienced a subjective increase in perception of fetal movements. All medications were continued with weekly monitoring of fetal weight and AFI. Gradually at 31 weeks, there was further decrease in pulsatility index, and S/D ratio was <3, in both umbilical and MCAs as shown in Figures 5 and 6. We report here the case of a 31-year-old female with infertility and preconceptional thin endometrium responding well to sildenafil citrate, followed by conception.

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In case of overdose, call the poison control helpline at 1-800-222-1222. Information is also available online at If the victim has collapsed, had a seizure, has trouble breathing, or can't be awakened, immediately call emergency services at 911. Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription. Keep a written list of all of the prescription and nonprescription (over-the-counter) medicines, vitamins, minerals, and dietary supplements you are taking.

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Bring this list with you each time you visit a doctor or if you are admitted to the hospital. You should carry the list with you in case of emergencies. Back to Journals » International Journal of Women's Health » Volume 8 Authors Choudhary R , Desai K, Parekh H, Ganla K Published 9 August 2016 Volume 2016:8 Pages 367—372 Editor who approved publication: Professor Elie Al-Chaer Rana Choudhary,1 Kavita Desai,2 Hetal Parekh,3 Kedar Ganla1 1Department of Reproductive Medicine, Ankoor Fertility Clinic, 2Department of Radiology, Dadar Imaging and Diagnostic Centre, 3IVF Department, Hiranandani Hospital, Mumbai, India Abstract: Fetal growth restriction (FGR) and preeclampsia are the major causes of neonatal morbidity and mortality, which affect up to 8% of all pregnancies. The pathogenesis in FGR is an abnormal trophoblastic invasion leading to compromised uteroplacental circulation. However, in spite of this understanding and identification of high-risk patients, the management options are limited.

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There are some new studies which have demonstrated the role of sildenafil citrate in improving vasodilatation of small myometrial vessels and therefore improvement in amniotic fluid index, fetal weight, and even uterine and umbilical artery Doppler patterns. We report here the case of a 31-year-old female with infertility and preconceptional thin endometrium responding well to sildenafil citrate, followed by conception. However, she presented with an early-onset FGR at 26 weeks of gestation, and again after treatment with sildenafil citrate, showed improvement in amniotic fluid index and fetal weight, finally resulting in delivery of a full-term healthy baby with uneventful neonatal course. Keywords: sildenafil citrate, fetal growth restriction, oligohydramnios, thin endometrium Early-onset fetal growth restriction (FGR) accompanied by severe oligohydramnios is often associated with high perinatal morbidity and mortality.1 Only a proportion of pregnancies with FGR show altered maternal peripheral vascular resistance, while some women may have elevated maternal peripheral vascular resistance in uterine arteries and hence poor perinatal outcome. In such pregnancies, if resistance values are normalized in later trimesters, there may be a significantly better outcome.2 Some recent studies have shown that sildenafil citrate increases uterine blood flow and potentiates estrogen-induced vasodilation.3 In this case of early-onset FGR, sildenafil citrate therapy was successful in managing FGR and accompanied severe oligohydramnios with a favorable neonatal and maternal outcome. However, she presented with an early-onset FGR at 26 weeks of gestation, and again after treatment with sildenafil citrate, showed improvement in amniotic fluid index and fetal weight, finally resulting in delivery of a full-term healthy baby with uneventful neonatal course. Keywords: sildenafil citrate, fetal growth restriction, oligohydramnios, thin endometrium Early-onset fetal growth restriction (FGR) accompanied by severe oligohydramnios is often associated with high perinatal morbidity and mortality.1 Only a proportion of pregnancies with FGR show altered maternal peripheral vascular resistance, while some women may have elevated maternal peripheral vascular resistance in uterine arteries and hence poor perinatal outcome. In such pregnancies, if resistance values are normalized in later trimesters, there may be a significantly better outcome.2 Some recent studies have shown that sildenafil citrate increases uterine blood flow and potentiates estrogen-induced vasodilation.3 In this case of early-onset FGR, sildenafil citrate therapy was successful in managing FGR and accompanied severe oligohydramnios with a favorable neonatal and maternal outcome. A 31-year-old female with a history of secondary infertility of 1 year and 6 months was referred to our clinic. She had two spontaneous miscarriages at tenth week of gestation, the last being 2 years and 6 months back, both followed by dilatation and curettage. After her last abortion, she did canada sildenafil not conceive for 2 years. Multiple cycles of ovulation induction with oral agents as well as injectable gonadotropins were done. All follicular studies showed consistently thin endometrium of 6–8 mm around the time of ovulation. On hysteroscopy done 1 year back, uterine cavity was normal. At our clinic, we started with follicular growth and endometrial thickness monitoring in natural cycle. Doppler for endometrial blood flow around the time of ovulation was suggestive of absent flow in zones 2, 3, and 4 of endometrium (Applebaum criteria).4,5 An attempt to improve the blood flow was made by starting Aspirin 75 mg, vitamin E, and Pentoxyfylline.6 However, repeat Doppler around the time of implantation did not show any improvement. In the next cycle, successful ovulation induction with gonodatropins was done, and trigger was given when the follicle was 18 mm, followed by intrauterine insemination. Luteal support was given with oral estrogen, progesterone, and vaginal Sildenafil citrate 25 mg (Alivher®; Akumentis Healthcare Ltd., Mumbai, India) twice a day in view of decreased endometrial blood flow in the previous cycle, which may be one of the causes of repeated abortions.7 Doppler for endometrial blood flow around the time of implantation (7–8 days after ovulation) showed good flow in all the zones.

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Fetal weight at that time was 440 g, and amniotic fluid index (AFI) was 10. Repeat ultrasound at sildenafil pfizer 100g 24 weeks was suggestive of oligohydramnios (AFI 6) with a fetal weight of 490 g (less than fifth percentile). Color Doppler in umbilical arteries showed normal systolic/diastolic (S/D) ratio, pulsatility index, and resistive index. However, there was notching seen in the uterine artery Doppler study. Investigations such as complete blood count, blood sugars, liver function test, renal function test, urine routine, and microscopy were within normal limits.

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Her blood pressure was normal; there was no peripheral pitting edema or proteinuria and hence no evidence of preeclampsia. The couple was informed regarding the guarded prognosis of pregnancy, and written informed consent was obtained voluntarily. The patient was kept on bed rest and given vitamin supplements, intravenous amino acid infusions, and nitric oxide donor (L-arginine sachets). Ultrasound at 26 weeks showed an estimated fetal weight of 550 g and an AFI of 4.5. Color Doppler showed an increased S/D ratio in the umbilical arteries with brain-sparing effect in the middle cerebral artery (MCA) as shown in Figures 1 and 2.

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A repeat ultrasonography at 27 weeks showed reduction in diastolic flow in the umbilical arteries. Figure 3 shows the ultrasonography Doppler image with reduced blood flow at the myometrial placental junction at diagnosis of intrauterine growth restriction. In view of grave prognosis of the pregnancy and unavailability of any other established definitive treatment, the couple was counseled regarding the limited role and experimental nature of Sildenafil citrate in oligohydramnios and FGR. After detailed counseling, the couple opted for Sildenafil citrate 25 mg vaginally twice a day. Repeat ultrasound at 28 weeks showed an improvement in blood flow and an increase in AFI to 6.5 with a fetal weight of 680 g after starting sildenafil citrate as shown in Figure 4. Serum β-human chorionic gonadotropin test done 14 days later confirmed the pregnancy. Sildenafil citrate was stopped on confirmation of pregnancy. Ultrasound at 12 weeks for nuchal translucency, nasal bone, and dual marker test were normal. Patient was called for follow-up visits every 3 weeks. Ultrasound for congenital malformation at 20 weeks did not reveal any abnormality. Fetal weight at that time was 440 g, and amniotic fluid index (AFI) was 10. Repeat ultrasound at sildenafil pfizer 100g 24 weeks was suggestive of oligohydramnios (AFI 6) with a fetal weight of 490 g (less than fifth percentile).

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The fetal well-being was continuously monitored using biophysical profile every 2 weeks. Sildenafil citrate therapy was stopped at 36 weeks. An elective cesarean section was done at 37th week for breech presentation, and a healthy female child of 2.3 kg was delivered. Baby cried immediately after birth, and Apgar score was 7/10 and 9/10 at 1 and 5 minutes, respectively. Placenta was examined after delivery; on gross examination, it was smaller in size (400 g) with areas of calcifications and increased thickness of membranes. Color Doppler in umbilical arteries showed normal systolic/diastolic (S/D) ratio, pulsatility index, and resistive index. However, there was notching seen in the uterine artery Doppler study. Investigations such as complete blood count, blood sugars, liver function test, renal function test, urine routine, and microscopy were within normal limits. Her blood pressure was normal; there was no peripheral pitting edema or proteinuria and hence no evidence of preeclampsia. The couple was informed regarding the guarded prognosis of pregnancy, and written informed consent was obtained voluntarily. The patient was kept on bed rest and given vitamin supplements, intravenous amino acid infusions, and nitric oxide donor (L-arginine sachets). Ultrasound at 26 weeks showed an estimated fetal weight of 550 g and an AFI of 4.5.

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A 31-year-old female with a history of secondary infertility of 1 year and 6 months was referred to our clinic. She had two spontaneous miscarriages at tenth week of gestation, the last being 2 years and 6 months back, both followed by dilatation and curettage. After her last abortion, she did canada sildenafil not conceive for 2 years. Multiple cycles of ovulation induction with oral agents as well as injectable gonadotropins were done. All follicular studies showed consistently thin endometrium of 6–8 mm around the time of ovulation.

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On hysteroscopy done 1 year back, uterine cavity was normal. At our clinic, we started with follicular growth and endometrial thickness monitoring in natural cycle. Doppler for endometrial blood flow around the time of ovulation was suggestive of absent flow in zones 2, 3, and 4 of endometrium (Applebaum criteria).4,5 An attempt to improve the blood flow was made by starting Aspirin 75 mg, vitamin E, and Pentoxyfylline.6 However, repeat Doppler around the time of implantation did not show any improvement. In the next cycle, successful ovulation induction with gonodatropins was done, and trigger was given when the follicle was 18 mm, followed by intrauterine insemination. Luteal support was given with oral estrogen, progesterone, and vaginal Sildenafil citrate 25 mg (Alivher®; Akumentis Healthcare Ltd., Mumbai, India) twice a day in view of decreased endometrial blood flow in the previous cycle, which may be one of the causes of repeated abortions.7 Doppler for endometrial blood flow around the time of implantation (7–8 days after ovulation) showed good flow in all the zones.

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Serum β-human chorionic gonadotropin test done 14 days later confirmed the pregnancy. Sildenafil citrate was stopped on confirmation of pregnancy. Ultrasound at 12 weeks for nuchal translucency, nasal bone, and dual marker test were normal. Patient was called for follow-up visits every 3 weeks. Ultrasound for congenital malformation at 20 weeks did not reveal any abnormality. Color Doppler showed an increased S/D ratio in the umbilical arteries with brain-sparing effect in the middle cerebral artery (MCA) as shown in Figures 1 and 2.

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On histopathological examination, there were areas of infarction. The maternal and neonatal courses were uneventful. We have followed up the child up to 14 months with normal mental and physical development. Adequate placental blood flow is essential for the optimal delivery of nutrients from mother to fetus and for growth of conceptus. A repeat ultrasonography at 27 weeks showed reduction in diastolic flow in the umbilical arteries. Figure 3 shows the ultrasonography Doppler image with reduced blood flow at the myometrial placental junction at diagnosis of intrauterine growth restriction. In view of grave prognosis of the pregnancy and unavailability of any other established definitive treatment, the couple was counseled regarding the limited role and experimental nature of Sildenafil citrate in oligohydramnios and FGR. After detailed counseling, the couple opted for Sildenafil citrate 25 mg vaginally twice a day.

• Sildenafil citrate tablets are typically taken 30-60 minutes before intimacy.
• Monitoring by a healthcare professional is recommended for women.
• Use sildenafil cautiously if you have a history of stroke or heart attack.
• Combining sildenafil with other ED medications is dangerous.
• Pregnancy and breastfeeding considerations should be discussed with a doctor.
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• Not suitable for women with or at risk of abnormal heart rhythms.
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Repeat ultrasound at 28 weeks showed an improvement in blood flow and an increase in AFI to 6.5 with a fetal weight of 680 g after starting sildenafil citrate as shown in Figure 4. The umbilical artery diastolic flow improved after 2 weeks of therapy, with no brain-sparing effect in MCA; however, the S/D ratio was >3. Furthermore, ultrasound at 30 weeks showed an AFI of 7.5 and a fetal weight of 1,000 g. The patient also experienced a subjective increase in perception of fetal movements. All medications were continued with weekly monitoring of fetal weight and AFI. Gradually at 31 weeks, there was further decrease in pulsatility index, and S/D ratio was <3, in both umbilical and MCAs as shown in Figures 5 and 6. The fetal well-being was continuously monitored using biophysical profile every 2 weeks. Sildenafil citrate therapy was stopped at 36 weeks. An elective cesarean section was done at 37th week for breech presentation, and a healthy female child of 2.3 kg was delivered. Baby cried immediately after birth, and Apgar score was 7/10 and 9/10 at 1 and 5 minutes, respectively.

• Sildenafil may improve blood flow to the clitoris, aiding arousal.
• Use caution with grapefruit or grapefruit juice, which can affect drug levels.
• Document any pre-existing medical conditions before starting sildenafil.
• Sildenafil may cause dizziness; avoid activities requiring alertness.
• Women with liver or kidney impairment should consult a physician first.
• The drug is not a hormone; it works on blood vessels.
• Patients should report any sustained erections or discomfort.
• Combining sildenafil with certain antidepressants may alter effectiveness.
• Keep track of any changes in sexual satisfaction or function.
• Sildenafil should be used as part of a comprehensive treatment plan.
• Avoid using sildenafil with recreational drugs that affect the cardiovascular system.
• Always follow up with your healthcare provider for ongoing assessment.

Placenta was examined after delivery; on gross examination, it was smaller in size (400 g) with areas of calcifications and increased thickness of membranes. On histopathological examination, there were areas of infarction. The maternal and neonatal courses were uneventful. We have followed up the child up to 14 months with normal mental and physical development. Adequate placental blood flow is essential for the optimal delivery of nutrients from mother to fetus and for growth of conceptus.