***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 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Obesity worsens and modest weight loss improves female fertility . Overweight women were r and omised to lifestyle or st and ard treatment pre‐in vitro fertilisation with treatment cessation at embryo transfer . There was a greater reduction in weight ( P < 0.001 ) for lifestyle treatment ( −3.8 ± 3.0 kg , P < 0.001 ) compared with no changes for st and ard treatment ( −0.5 ± 1.2 kg , P = 0.092 ) . Both the intervention ( −5.3 ± 4.6 cm ) and control ( −3.5 ± 3.5 cm ) group had reductions in waist circumference ( P < 0.001 ) with no differences between the two groups ( P = 0.215 ) . The overall pregnancy rate was 53 % ( 20/38 ) for the intervention and control group combined OBJECTIVE To evaluate the effect of acupuncture on the pregnancy rate in assisted reproduction therapy ( ART ) by comparing a group of patients receiving acupuncture treatment shortly before and after embryo transfer with a control group receiving no acupuncture . DESIGN Prospect i ve r and omized study . SETTING Fertility center . PATIENT(S ) After giving informed consent , 160 patients who were undergoing ART and who had good quality embryos were divided into the following two groups through r and om selection : embryo transfer with acupuncture ( n = 80 ) and embryo transfer without acupuncture ( n = 80 ) . INTERVENTION(S ) Acupuncture was performed in 80 patients 25 minutes before and after embryo transfer . In the control group , embryos were transferred without any supportive therapy . MAIN OUTCOME MEASURE(S ) Clinical pregnancy was defined as the presence of a fetal sac during an ultrasound examination 6 weeks after embryo transfer . RESULT ( S ) Clinical pregnancies were documented in 34 of 80 patients ( 42.5 % ) in the acupuncture group , whereas pregnancy rate was only 26.3 % ( 21 out of 80 patients ) in the control group . CONCLUSION ( S ) Acupuncture seems to be a useful tool for improving pregnancy rate after ART OBJECTIVE To replicate previous research on the efficacy of acupuncture in increasing pregnancy rates ( PR ) in patients undergoing IVF and to determine whether such an increase was due to a placebo effect . DESIGN Prospect i ve , r and omized , controlled , single blind trial . SETTING Private , academically affiliated , infertility clinic . PATIENT(S ) One hundred fifty patients scheduled to undergo embryo transfer . INTERVENTION(S ) Subjects were r and omized to either the acupuncture or control group . Acupuncture patients received the protocol , as first described by Paulus and his colleagues , for 25 minutes before and after embryo transfer . Control subjects laid quietly . All subjects then completed question naires on anxiety and optimism . The IVF staff remained blind to subject assignment . MAIN OUTCOME MEASURE(S ) Clinical PRs , anxiety , optimism . RESULT ( S ) Before r and omization both groups had similar demographic characteristics including age and psychological variables . There were no significant differences in PRs between the two groups . Acupuncture patients reported significantly less anxiety post-transfer and reported feeling more optimistic about their cycle and enjoyed their sessions more than the control subjects . CONCLUSION ( S ) The use of acupuncture in patients undergoing IVF was not associated with an increase in PRs but they were more relaxed and more optimistic STUDY QUESTION Is expressive writing intervention ( EWI ) efficacious in reducing distress and improving pregnancy rates for couples going through ART treatment ? SUMMARY ANSWER Compared to controls , EWI statistically significantly reduced depressive symptoms but not anxiety and infertility-related distress . WHAT IS KNOWN ALREADY ART treatment is considered stressful . So far , various psychological interventions have been tested for their potential in reducing infertility-related distress and the results are generally positive . It remains unclear whether EWI , a brief and potentially cost-effective intervention , could be advantageous . STUDY DESIGN SIZE , DURATION Between November 2010 and July 2012 , a total of 295 participants ( 163 women , 132 men ) were r and omly allocated to EWI or a neutral writing control group . PARTICIPANTS / MATERIAL S , SETTING , METHODS Participants were couples undergoing IVF/ICSI treatment . Single women and couples with Preimplantation Genetic Diagnosis or acute change of procedure from insemination to IVF , were excluded .  EWI participants participated in three 20-min home-based writing exercises focusing on emotional disclosure in relation to infertility/fertility treatment ( two sessions ) and benefit finding ( one session ) . Controls wrote non-emotionally in three 20-min sessions about their daily activities . The participants completed question naires at the beginning of treatment ( t1 ) , prior to the pregnancy test ( t2 ) , and 3 months later ( t3 ) . In total , 26.8 % ( 79/295 ) were lost to follow-up . Mixed linear models were chosen to compare the two groups over time for psychological outcomes ( depression , anxiety and infertility-related distress ) , and a Chi2 test was employed in order to examine group differences in pregnancy rates MAIN RESULTS AND THE ROLE OF CHANCE One hundred and fifty-three participants received EWI ( women = 83 ; men = 70 ) and 142 participants were allocated to the neutral writing control group ( women = 83 ; men = 62 ) . Both women and partners in the EWI group exhibited greater reductions in depressive symptoms compared with controls ( P = 0.049 ; [ CI 95 % : −0.04 ; −0.01 ] Cohen 's d = 0.27 ) . The effect of EWI  on anxiety did not reach statistical significance . Overall infertility-related distress increased marginally for the partners in the EWI group compared to the partners in the control group ( P = 0.06 ; Cohen 's d = 0.17 ) . However , in relation to the personal subdomain , the increase was statistically significant ( P = 0.01 ; Cohen 's d = 0.24 ) . EWI had no statistically significant effect on pregnancy rates with 42/83 ( 50.6 % ) achieving pregnancy in the EWI group compared with 40/80 ( 49.4 % ) in the control group ( RR = 0.99 [ CI 95 % = 0.725 , 1.341 ] ; P = 0.94 ) . LIMITATIONS , REASONS FOR CAUTION The results for depressive symptoms corresponded to a small effect size and the remaining results failed to reach statistical significance . This could be due to sample characteristics leading to a possible floor-effect , as we did not exclude participants with low levels of emotional distress at baseline . Furthermore , men showed increased infertility-related distress over time . WIDER IMPLICATION S OF THE FINDINGS EWI is a potentially cost-effective and easy to implement home-based intervention , and even small effects may be relevant . When faced with infertility , EWI could thus be a relevant tool for alleviating depressive symptoms by allowing the expression of feelings about infertility that may be perceived as socially unacceptable . However , the implication s do not seem to be applicable for men , who presented with increased infertility-related distress  over time . STUDY FUNDING /COMPETING INTEREST(S ) The present study was supported by research grants from Merck Sharpe and Dohme and The Danish Agency for Science Technology and Innovation as part of a publicly funded PhD. The funding bodies had no influence on the data collection , analysis or conclusions of the study . None of the authors have any conflicts of interest to declare . TRIAL REGISTRATION NUMBER Clinical trials.gov , trial no. NCT01187095 . TRIAL REGISTRATION DATE 7th September 2010 DATE OF FIRST PATIENT 'S ENROLMENT 23rd November So far , the beneficial effects of personal written emotional disclosure have been mainly examined in relation to past or current stressful/traumatic experiences . The anticipation of a medical event has rarely been studied within this paradigm . This r and omized-controlled study examined whether written emotional disclosure would reduce emotional distress and increase pregnancy rates in women undergoing in-vitro fertilization treatment . Participants recruited from women who were undergoing IVF in the north of Greece ( n=148 ) were r and omized to an emotional-writing condition , a fact-writing condition and a control condition . Outcomes included fertility-related distress , general distress and a positive indication of pregnancy . Psychological and medical information about women who refused to participate were also collected , and this represented a fourth group for analysis ( n=66 ) . Results indicated no significant difference between groups in terms of emotional distress . However , a significant difference was observed with regard to pregnancy results , with the non- participants group reporting the highest percentage of pregnancies . The present study did not support the hypotheses that emotional disclosure will reduce infertility-related or general psychological distress and improve pregnancy outcomes in women undergoing in-vitro fertilization treatment . However , women who refused to participate in the study were more likely to get pregnant . Differences in the beneficial effects of emotional disclosure are discussed OBJECTIVE To evaluate the influence of " true " versus " sham " acupuncture on pregnancy rates ( PRs ) in women undergoing IVF . DESIGN R and omized controlled trial , double-blinded with independent observer . SETTING Academic infertility clinic . PATIENT(S ) One hundred sixty patients < 38 years old undergoing IVF with or without intracytoplasmic sperm injection . INTERVENTION(S ) Subjects were r and omly allocated to the true or sham group and underwent acupuncture 25 minutes before and after ET . Subjects completed a McGill Pain Question naire regarding their clinical symptoms during ET . MAIN OUTCOME MEASURE(S ) Clinical PR and clinical symptoms during ET . RESULT ( S ) While the overall clinical PR was 51.25 % , there was no significant difference between the arms of the study ( true = 45.3 % vs. sham = 52.7 % ) ; 33.1 % of the patients had ultrasound-documented singleton pregnancy , and 15 % of patients had twin gestations , while one patient in the true arm had a triplet gestation . There were significant differences in the subjective , affective , and total pain experience between both arms . The subjects in the true arm described their acupuncture session as being more " tiring " and " fearful " and experienced more " achiness " compared with their sham counterparts . CONCLUSION ( S ) There was no statistically significant difference in the clinical or chemical PRs between both groups . Patients undergoing true acupuncture had differing sensory experiences compared with patients in the sham arm . There were no significant adverse effects observed during the study , suggesting that acupuncture is safe for women undergoing ET OBJECTIVE To determine the effect of luteal-phase acupuncture on the outcome of  IVF/intracytoplasmic sperm injection ( ICSI ) . DESIGN R and omized , prospect i ve , controlled clinical study . SETTING University IVF center . PATIENT(S ) Two hundred twenty-five infertile patients undergoing IVF/ICSI . INTERVENTION(S ) In group I , 116 patients received luteal-phase acupuncture according to the principles of traditional Chinese medicine . In group II , 109 patients received placebo acupuncture . MAIN OUTCOME MEASURE(S ) Clinical and ongoing pregnancy rates . RESULT ( S ) In group I , the clinical pregnancy rate and ongoing pregnancy rate ( 33.6 % and 28.4 % , respectively ) were significantly higher than in group II ( 15.6 % and 13.8 % ) . CONCLUSION ( S ) Luteal-phase acupuncture has a positive effect on the outcome of IVF/ICSI In this r and omized study , influences of dietary sodium restriction as an independent factor on anxiety levels of women participating in an in vitro fertilization-embryo transfer ( IVF-ET ) procedure were investigated .  Anxiety levels of 119 women were measured using the Spielberger State and Trait Anxiety Inventory . Data of 69 women remained for analysis . Drop-outs , mainly due to cycle cancellations , tended to have higher mean state anxiety scores compared with women who continued ( p = 0.11 ) . Bias by selection affected both diet groups in similar proportions . State as well as trait anxiety scores increased significantly ( p = 0.01 , and p = 0.03 , respectively ) from baseline ( before ovarian stimulation ) to the point of measurement in the luteal phase . No significant differences in this mean increase were observed between the two diet groups . The significantly higher mean increase in state and trait anxiety in conceiving women was striking compared with those who did not conceive ( p = 0.03 and p < 0.01 , respectively ) . We conclude that dietary sodium restriction does not lower anxiety levels during an IVF-ET procedure . Anxiety levels increase more from baseline ( before ovarian stimulation ) to the luteal phase in conceiving than in nonconceiving women . The influence of conception on anxiety levels needs further investigation Purpose To determine if acupuncture improves symptoms of anxiety in infertile women undergoing in vitro fertilisation ( IVF ) treatment . Methods A r and omised clinical trial was performed in 43 patients undergoing IVF . The patients were r and omised into two groups : test group ( n=22 ) and control group ( n=21 ) . The anxiety level of each patient was analysed before and after treatment using the Hamilton Anxiety Rating Scale ( HAS ) . 
    Output:
    
Nonpharmacological interventions  reduced anxiety when compared with control interventions ( SMD 0.25 , 95 % confidence interval 0.08 - 0.42 ; I2 = 85 % ) , but they had no significant effects on depression and infertility distress .
CONCLUSIONS Nonpharmacological interventions could improve the psychological outcomes of patients undergoing ART treatment