***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: OBJECTIVE To assess the efficacy of a clomiphene citrate ( CC ) and tamoxifen citrate ( CC/tamoxifen ) combination therapy in ovulation induction by comparing with a CC alone therapy . DESIGN A r and omized cross-over study with CC alone and CC/tamoxifen combination therapies for 20 normoprolactinemic anovulatory women . R and omly selected 10 of the 20 women ( group A ) underwent a CC alone therapy ( 100 mg CC during cycle days 5 to 9 ) for the initial three consecutive treatment cycles and a CC/tamoxifen combination therapy ( 50 mg CC and 20 mg tamoxifen during cycle days 5 to 9 ) for the subsequent three consecutive treatment cycles . The remaining 10 ( group B ) were treated similarly but with the inverse sequence . Ovulation was documented when a high BBT phase persisted for 11 days or more , when midluteal serum P levels exceeded 7 ng/mL ( 22.3 nmol/L ) , or when pregnancy ensued . RESULTS The rates of ovulatory/treated , pregnant/treated , and pregnant/ovulatory cycles were 42 of 56 ( 75.0 % ) , 3 of 47 ( 6.4 % ) , and 3 of 35 ( 8.6 % ) for CC/tamoxifen , respectively . Those were 25 of 57 ( 43.9 % ) , 1 of 48 ( 2.1 % ) , and 1 of 21 ( 4.8 % ) for CC , respectively . Clomiphene citrate/tamoxifen was more effective in ovulation induction than CC . All the pregnancies were normal and single . None of the treatments was accompanied by any remarkable side effects . CONCLUSION Clomiphene citrate/tamoxifen is a novel treatment modality of ovulation induction with high efficacy OBJECTIVE --To determine whether pituitary suppression before induction of ovulation reduces the rate of spontaneous abortion in women with polycystic ovarian disease and primary recurrent spontaneous abortions . DESIGN --Closed , r and omised , sequential trial . Pairs of women were allocated to each treatment by the toss of a coin . SETTING --Supraregional clinic for women who had had recurrent spontaneous abortions . SUBJECTS -- Forty two women with polycystic ovarian disease and primary recurrent spontaneous abortions . INTERVENTIONS --Ovulation was induced by clomiphene or pituitary suppression with buserelin followed by pure follicle stimulating hormone . MAIN OUTCOME MEASURES --Preference for a particular treatment was noted . A preference occurred when one woman in a pair had a successful pregnancy ( defined as one of over 12 weeks ' gestation ) and one had a spontaneous abortion ; the preference was for the treatment result ing in the successful pregnancy . RESULTS --Spontaneous abortions occurred in 11 of 20 women given clomiphene compared with two of 20 who had pituitary suppression . Eleven preferences were found for buserelin and two for clomiphene . In seven pairs both women had successful pregnancies . One pair was discarded because one of the women did not become pregnant . The ratio of luteinising hormone concentration to follicular diameter was found to be a possible diagnostic indicator of spontaneous abortion . CONCLUSION --Pituitary suppression before induction of ovulation significantly reduces the risk of spontaneous abortion in women with polycystic ovarian disease and primary recurrent spontaneous abortions Antiestrogens are widely used to treat eugonadal anovulation , luteal phase deficiency ( LPD ) and oligospermia . This paper review s the rationale s , endocrine effects , profertility effects and side effects of these treatments . Furthermore , we present our own experience of the use of antiestrogens in this field . We have compared the results of clomiphene citrate ( CC ) to those of tamoxifen ( TAM ) in a r and omized study including 66 infertile women presenting eugonadal anovulation ( n = 26 ) or LPD ( n = 40 ) . Both drugs obtained the same pregnancy rate of 80 % at 9 months in the anovulatory patients . Conversely , CC was superior to TAM in the LPD cases ( pregnancy rates at 6 months of respectively 40 and 11 % ) . The abortion rates were of 11 % on CC versus 36 % on TAM . Both drugs significantly increased the luteal phase length and plasma progesterone level to the same extent . The results of endometrial biopsies suggest that the difference in their effects on female fertility could result from a detrimental effect of TAM on endometrium . The rates of the side effects proved to be almost identical on both drugs . Thus the use of TAM is not justified as a first-step treatment in ovulation disturbances . TAM should be reserved for patients who experience severe visual side effects on CC . We have also tested  TAM in 100 subfertile males . In the 92 oligospermic males , TAM significantly increased the mean sperm count only in the normogonadotropic patients , but as much whether oligospermia was idiopathic or not . Sperm improvement was not significantly related to any hormone criterion except basal serum FSH . The cumulative pregnancy rate was of 41.2 % at 1 year . Whether TAM actually improves male fertility , and is superior to CC in this indication , remains to be confirmed in controlled studies Abstract Purpose : To study the effect of CYP17a inhibitor , “ ketoconazole , ” on clomiphene responsiveness in PCOS patients . Methods : Prospect i ve analysis was employed with the setup at Alex and ria IVF/ICSI center . Ninety-seven insulin-resistant PCOS patients undergoing ovulation induction using clomiphene citrate  were r and omly divided , by r and om number table , into two groups . The first group ( n = 49 ) received ketoconazole ( 400 mg daily ) till correction of metabolic syndrome followed by clomiphene ( 100 mg/day ) ; the second group ( n = 48 ) receiving clomiphene without ketoconazole pretreatment . Main outcome measures were incidence of clomiphene resistance , monofollicular response , fasting insulin/glucose ratio , serum testosterone , and pregnancy rates . Results : The ketoconazole group showed significantly ( p < 0.05 ) higher incidence of monofollicular response ( 38 % ) , higher pregnancy rates , and significantly less marked antiestrogenic manifestations than did the control group . They also had significantly lower incidence of clomiphene resistance ( 11.6 % ) , lower serum testosterone levels , less hyperinsulinaemia , than did the control group . Conclusion : Ketoconazole improved clomiphene responsivenss in PCOS patients and attenuated its untoward biological effects Objective To determine the efficacy of pulsatile GnRH alone and in combination with clomiphene citrate or gonadotropins in a stepwise approach for inducing ovulation in women with clomiphene-resistant polycystic ovary syndrome ( PCOS ) . Methods Eighty women with clomiphene-resistant anovulatory infertility and PCOS were given subcutaneous pulsatile GnRH ( 15 μg every 90 minutes ) using a portable infusion pump . If no follicular development was seen , clomiphene citrate ( 100 mg/day for 5 days ) was given concurrently with the hormone in the next cycle of treatment . Those who still failed to ovulate regularly were treated with combined pulsatile GnRH with intramuscular gonadotropins ( one ampule per day for 5–7 days ) . Results Sixty-six of 131 ( 50 % ) pulsatile GnRH cycles , 94 of 142 ( 66 % ) pulsatile GnRH with clomiphene cycles , and 48 of 69 ( 70 % ) pulsatile GnRH with gonadotropin cycles were ovulatory . Monofollicular response ( one follicle at least 14 mm on the day of ovulation ) occurred in 80.6 , 83.9 , and 53.6 % of cycles , and multifollicular response occurred in 4.8 , 3.1 , and 21.6 % of cycles in the three groups , respectively . Mild ovarian hyperstimulation occurred in one of the 342 cycles . The cumulative conception rate was 30 % after three cycles , 60 % after six cycles , and 73 % after nine cycles . The miscarriage rate was 22 % ( ten of 45 pregnancies ) , and 35 women ( 78 % ) had live births ( 33 singletons and two sets of twins ) . Conclusion The use of subcutaneous pulsatile GnRH alone and in combination with clomiphene citrate or gonadotropins for induction of ovulation in clomiphene-resistant PCOS in a stepwise approach produces a high cumulative conception rate associated with a low rate of multiple pregnancy and ovarian hyperstimulation syndrome OBJECTIVE To use aromatase inhibition for induction of ovulation in women in whom clomiphene citrate ( CC ) treatment was unsuccessful . DESIGN Prospect i ve trial in infertility patients treated with CC .  SETTING Two tertiary-referral infertility clinics associated with the Division of Reproductive Sciences , University of Toronto . PATIENT(S ) Twelve patients with anovulatory polycystic ovary syndrome ( PCOS ) and 10 patients with ovulatory infertility , all of whom had previously received CC with an inadequate outcome ( no ovulation and /or endometrial thickness of < or = 0.5 cm ) . INTERVENTION(S ) The aromatase inhibitor letrozole was given orally in a dose of 2.5 mg on days 3 - 7 after menses . MAIN OUTCOME MEASURE(S ) Occurrence of ovulation , endometrial thickness , and pregnancy rates . RESULT ( S ) With CC treatment in patients with PCOS , ovulation occurred in 8 of 18 cycles ( 44.4 % ) , and all ovulatory cycles for the women included in this study had endometrial thickness of < or = 0.5 cm . In 10 ovulatory patients , 15 CC cycles result ed in a mean number of 2.5 mature follicles , but all cycles had endometrial thickness of < or = 0.5 cm on the day of hCG administration . With letrozole treatment in the same patients with PCOS , ovulation occurred in 9 of 12 cycles ( 75 % ) and pregnancy was achieved in 3 patients ( 25 % ) . In the 10 patients with ovulatory infertility , letrozole treatment result ed in a mean number of 2.3 mature follicles and mean endometrial thickness of 0.8 cm . Pregnancy was achieved in 1 patient ( 10 % ) . CONCLUSION ( S ) Oral administration of the aromatase inhibitor letrozole is effective for ovulation induction in anovulatory infertility and for increased follicle recruitment in ovulatory infertility . Letrozole appears to avoid the unfavorable effects on the endometrium frequently seen with antiestrogen use for ovulation induction Improved underst and ing of follicular dynamics has led to a reevaluation of suppression of adrenal and rogens in ovulation induction . To test whether adrenal suppression during clomiphene citrate ( CC ) therapy would improve ovulation/pregnancy rates , 64 anovulatory patients who had not previously received CC were r and omly assigned to receive either 50 mg CC on days 5 to 9 alone or with 0.5 mg dexamethasone ( CC + DEX ) . Patients were then screened for  dehydroepi and rosterone sulfate ( DHEA-S ) ( normal range , 80 to 320 micrograms/dl ) , prolactin , testosterone , and semen analysis of the partner . Nine patients discontinued participation prior to completing the first treatment cycle , and ten patients were found to have either elevated prolactin  ( 4 ) ,  severe male factors  ( 3 ) , or  tubal disease  ( 3 ) and were discontinued . CC was increased 50 mg/day per cycle through 150 mg/day until ovulation occurred . Once the patient was ovulatory on therapy , a properly timed postcoital test and endometrial biopsy for luteal phase defect were performed . If anovulatory at 150 mg/day of CC or demonstrating abnormal postcoital test or endometrial biopsy at 150 mg/day of CC , patients were crossed to the other arm of the treatment protocol . The results revealed a significantly higher rate of ovulation ( P less than 0.01 ) and conception ( P less than 0.05 ) in the CC + DEX-treated group . When correlated with DHEA-S levels , this improvement occurred in patients with DHEA-S greater than 200 micrograms/dl ( P less than 0.05 ) OBJECTIVE To evaluate the role of ketoconazole in prevention of ovarian hyperstimulation syndrome ( OHSS ) in women with the polycystic ovary syndrome ( PCOS ) undergoing ovarian stimulation with gonadotropins . DESIGN Prospect i ve , r and omized , double-blind , placebo-controlled study . SETTING University hospitals . One hundred nine women with PCOS who were referred for treatment with gonadotropins . INTERVENTION(S ) Fifty patients were r and omly assigned to receive two ampoules of hMG beginning on day 2 or 3 of the cycle and ketoconazole ( 50 mg every 48 hours ) starting on the first day of hMG treatment .  Fifty-one patients received the same amount of hMG plus one 
    Output:
    
Miscarriage and multiple pregnancy rates were poorly reported .
This review shows evidence supporting the effectiveness of the current first line treatment , clomiphene citrate .
No evidence of a difference in effect was found between clomiphene and tamoxifen .
The use of dexamethasone as an adjunct to clomiphene therapy appears promising as do combined oral contraceptives .