# Ectopic / Methotrexate



## magot

Can anyone offer advice please?

History: Thought I had miscarriage 2nd January as after bleeding since xmas eve and having bad stomach cramps, I had something in my underwear. I keep having scans and last week they found something by my ovary and they were not sure of significance so as I am still bleeding, have abdo pain; feel light headed and more importantly my HCG levels are not decreasing much they booked further rescan and HCG. I should point out here that this was my 5th scan and no sac has ever been found in my uterus. 

Scan today showed nothing in uterus (expected) but the something by ovary is still there albeit smaller, and my HCG levels are not decreasing, they are not increasing either. As this has been ongoing for 3.5 weeks they have now offered me the following:
1)	Continue to watch and wait, have rescan and HCG again in a weeks 
time and see what happens. (Ideally waiting for nature and my body to 
complete the process but not guarenteed)
2)	Medical management by way of Methotrexate injection 
3)	Laparoscopy (although they did not advise this)


What Id like to know is, 

Has anyone been offered Methotrexate and taken it? What was it like? Symptoms? Problems since? Would you recommend it to me or not?

Has anyone been offered Methotrexate and decline it? Why? Did nature take its course?


If anyone reading this has had an ectopic before and can share your story Id be grateful as Im worried about everything.


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## Eternal

my mum has is for other reasons every week, i think it kind of gets worse over time. lots of women on here i have heard them say they were surprised as they felt fine.

what i would consider though is that if you do take it you cant conceive (i think it is for a 100 days) for awhile. 

If they are still not sure whats going on then would the surgery not offer a better in way of explanation? saying that if they are not advising this its maybe better not to have it. 

Im sorry for your loss and having to make this decision. good luck


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## magot

Eternal said:


> my mum has is for other reasons every week, i think it kind of gets worse over time. lots of women on here i have heard them say they were surprised as they felt fine.
> 
> what i would consider though is that if you do take it you cant conceive (i think it is for a 100 days) for awhile.
> 
> If they are still not sure whats going on then would the surgery not offer a better in way of explanation? saying that if they are not advising this its maybe better not to have it.
> 
> Im sorry for your loss and having to make this decision. good luck


Thank you. I was told that with 1 injection we cant conceive for 3-4 months but if we require a second injection then this would take it to 6 months. So it's tough decision especially when we really want a baby however, trying to be positive we are both only 26 therefore we hopefully have plenty of time. 

We were told the operation could cause damage and would be a last resort if they could help it.


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## Anna Purna

I'm so sorry. :hugs:
I had an ectopic in June at 10 weeks and 5 days. I was given a shot of methotrexate and was told to hold off on TTC for 3 months.
After the shot the pain decreased and I almost instantly lost the pregnancy symptoms. I bled on and off for about a month, then had nothing for a month, then started to get regular periods. 
I honestly can't recall there being any huge side-effects; I guess I was too busy being sad.:cry: I would definitely recommend taking some time off work if you can. I was an emotional wreck afterwards. 
Perhaps the only 'side effect' is that afterwards I was painfully aware of every cramp and slight pain going on down there. Periods and ovulation are definitely more intense and noticeable. 
I was given the choice between methotrexate and surgery, and I'm glad I chose methotrexate. From what I've read, your chances of conceiving again after methotrexate are significantly higher and there's less of a risk of it being another ectopic. 
I think you're 'lucky' (I know, how can that be true?) that the baby wasn't in a tube, as this could cause more trouble in the future. Mine was also outside the tube, which was why I didn't have problems until almost 11 weeks into it.
Good luck. I hope you have a good support system during this, and don't forget to take care of yourself.
p.s. I had my ectopic in June, and I just got my :bfp: today. So, there is hope of conceiving after an ectopic. :thumbup:


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## misspink

Anna Purna said:


> I'm so sorry. :hugs:
> I had an ectopic in June at 10 weeks and 5 days. I was given a shot of methotrexate and was told to hold off on TTC for 3 months.
> After the shot the pain decreased and I almost instantly lost the pregnancy symptoms. I bled on and off for about a month, then had nothing for a month, then started to get regular periods.
> I honestly can't recall there being any huge side-effects; I guess I was too busy being sad.:cry: I would definitely recommend taking some time off work if you can. I was an emotional wreck afterwards.
> Perhaps the only 'side effect' is that afterwards I was painfully aware of every cramp and slight pain going on down there. Periods and ovulation are definitely more intense and noticeable.
> I was given the choice between methotrexate and surgery, and I'm glad I chose methotrexate. *From what I've read, your chances of conceiving again after methotrexate are significantly higher and there's less of a risk of it being another ectopic. *I think you're 'lucky' (I know, how can that be true?) that the baby wasn't in a tube, as this could cause more trouble in the future. Mine was also outside the tube, which was why I didn't have problems until almost 11 weeks into it.
> Good luck. I hope you have a good support system during this, and don't forget to take care of yourself.
> p.s. I had my ectopic in June, and I just got my :bfp: today. So, there is hope of conceiving after an ectopic. :thumbup:

Hi,
I had surgery for an ectopic last march and here in the UK we're told there is pretty much no difference between chance of suffering another ectopic whether we have surgery or metotrexate because the mtx causes scarring in the affected tube. We're also told that the chance of conceiving is not much different because as long as there are ovaries and one healthy tube there's a very high chance of conceiving again. Also, conservative estimates show that about 15% of the time the opposite tube picks up the egg so if you have no left tube and ovulate from your right side you can still end up pregnant. 
Would you mind me asking where you were told that?


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## chickchock

Hi. Just want to reiterate what misspink said wave:). I also had my tube removed last year and I have two ovaries and one tube. I've never been told that the chances are any different, and they advised surgery for me as they said if the methotrextae didn't work, I'd have to have surgery anyway.

I can kind of see why they might not want to do surgery on you if it is actually near your ovary, as I suppose they could risk damage to the ovary, leaving you with only one? I don't have experience of methotrexate so sorry can't be much help on that.

Have a look on ectopic pregnancy trust website if you can, there are lots of women who've been through the same and also some proffessionals I believe who can answer your questions x x


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## Anna Purna

Hey ladies. First of all, I hope I haven't offended anyone with my comment. I was just going by what the ER doctor had told me and from I'd read on some websites. That being said, when I just re-did some 'research' on the Internet I couldn't find evidence to support what I said. :shrug: I guess after my ectopic I was looking for any glimmer of hope, so I understood what I wanted to be true. I'm going to look into it bit more, though, as I feel quite stupid for 'making up' these stats. 
So, I eat my words. Perhaps the doctor just wanted me to choose methotrexate because it was cheaper and easier for the hospital. I wouldn't be surprised. :nope:
Anyways, I hope everything has worked out for you Magot. Take care.


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## heather_marie

I've had 3 ectopics and with my first one they gave me a shot of methotrexate. I didn't have any symptoms from it (either that or I didn't notice because I was already in so much pain anyway from the ectopic) and they had to end up doing a surgery afterall because they thought my tube had ruptured. Thankfully it hadn't. With that being said, I haven't heard anything about it making it harder to concieve (after the wait time is over). That is a hard decision you have to make and I'm very sorry you have to go through that. I've been there three times. I can tell you that sometimes the longer you wait the more damage it could do to your tube. With my last one by the time I made a decision to go with the surgery my tube was so damaged it had to be removed. Let us know if there are any updates and take are of yourself!


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## Lucy28

I was given methtrexate for a possible ectopic pregnancy. My doctor made the decision solely based on hcg levels, and they told me I had to get the methotrexate shot immediately because my life was at stake. I got the shot, then my GP (different doctor) did an ultrasound and it was in the uterus. But it was too late.

Three months later I got pregnant again, and this time everything is going well.. and I have twins! I don't know what to think about what happened with the possible ectopic and methotrexate, but if you have hcg issues AND your ultrasound backs up the ectopic theory, I would do the methotrexate. I had no side effects, and I was given the ok to try again three months later, and that is exactly when I got pregnant again.

I am so sorry for this- I know how painful this is. I went in to get the metho shot and they accidentally sent me to the maternity ward. I was hysterical and they sent me home with a stupid booklet about how to deal with miscarriage. Bring someone with you- I wish I had. The whole thing was over about 6 days later. Be good to yourself and let yourself grieve.
XX


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## misspink

Omg Lucy that is so awful I can't believe they did that to you, you poor thing. They should have scanned you to see if there was anything in the uterus not just given you the mtx. I was told by my epau that slow rising levels aren't always an indication of ectopic, on occasions, clearly yours was one, nothing is wrong at all. I'd definitely go ahead with the legal action if you can cope with it.
Congrats on your bfp and twins!


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## Alivia40

Lucy28..... I was also given the methotrexate solely based on hcg levels... had mild groin pain on sunday, dpo23 my level was 336 and there was nothing at all seen on ultrasound. either in tubes or uterus. my levels were dpo16-72, dpo18-119 dpo19-151 dpo23-336 dpo25-361. then the day I got the shot which was dpo26 it jumped to 552. I hesitated on getting the shot, but I spoke to the doctor and she said she was sure ectopic and if I don't get the shot I run risk of rupture and hemmorrage, so I got it. Now I'm waiting.... haven't really had much pain through the whole thing, extremely mild and not constant, never constant. had labs drawn today and will on wednesday. not really sure what to think..... I really pray I did not abort this baby needlessly. 

Medical treatment with methotrexate


Browse: Home / For patients / Treatment / Medical treatment with methotrexate


The term medical management, when used in relation to ectopic pregnancy, means using a drug called methotrexate.

What is methotrexate?

Methotrexate is a powerful drug which works by interfering, in a temporary way, with the processing in the body of an essential vitamin called folate. Folate is needed to help rapidly dividing cells  such as those of a pregnancy. The drug stops the pregnancy developing any further and the pregnancy is gradually reabsorbed. Methotrexate is also used to try and control other unwanted rapidly dividing cells, such as those which cause the condition rheumatoid arthritis, psoriasis, and some specialised cancerous lesions.

When is treatment with methotrexate most appropriate?

This method of treatment is more suitable for some women than others and is more likely to be successful in the following circumstances:
You are in good health
Your tube has not ruptured
Your hCG level is low (your hospital will probably have a level above which this method will not be used)
There is no signifiant abdominal bleeding.

Because it does not entail an operation, this method has an advantage over keyhole (or open) surgery if:
You have other medical problems that may increase the risks of a general anaesthetic
If you have adhesions in the abdomen or pelvis (as a result of previous surgery or infection)
The ectopic pregnancy is situated in the neck of the womb or as the tube enters the womb.

Treatment of ectopic pregnancy with methotrexate is not appropriate if you suffer from any of the following conditions:
An ongoing infection
Severe anaemia or shortage of other blood cells
Kidney problems
Liver problems
Active infection
HIV/AIDS
Peptic ulcer or ulcerative colitis.

How is the treatment given?

The treatment is given by means of an injection, usually given by a single injection into the muscle. However, if it needs to be administered by any other route, this will be discussed with you. The dose is calculated according to your height and weight. Before the injection, blood tests are done to check liver and kidney function and to ensure that you are not anaemic. Every 2-3 days, beta hCG levels will be monitored to ensure that they are falling appropriately. Most women only need one injection but in up to a quarter of cases a further injection may be required if serum hCG levels are not decreasing.

What happens after treatment?

This method has been developed to avoid surgery. However, it does require careful monitoring and follow-up. This means that you will have to attend the hospital regularly for blood tests until the tests are negative. This can take several weeks and this will be explained by your doctor. Your hospital will make arrangements for you to have the hormone level checked. Your doctors will usually test your hCG levels on the day the medicine is given, again on day 4, and on day 7 after the injections.

The hCG level often rises on day 4 and then your doctors are looking to see a drop in your hCG value of at least 15% between days 4 and 7. A few days after the injection, it is usual to begin to bleed and this bleeding can last between a few days and up to 6 weeks. It is usual to have some discomfort and pain initially but as long as this is not severe and you are feeling well this is nothing to worry about. If the pain persists for longer than 10 days, or is severe and is not helped by taking paracetamol, or you feel faint, you will need to go to hospital immediately as this may be a sign that the tube has ruptured.

What can I do to help the treatment work?
You should stop taking any vitamins, minerals or other medicines unless you have been told by the doctors treating you to continue with them. Some medicines interfere with the effects of methotrexate. It is particularly important that you do not take any folic acid supplements until your doctors are sure that the medicine has worked
You should not do any heavy lifting or housework until the hCG levels are dropping consistently and should only undertake gentle exercise, such as walking, until the hCG levels are below 100<mIU/mL
You should avoid sexual intercourse until your levels are down to less than 100<mIU/mL
Most people take time off from work initially and do not return to work for around 2 weeks while the treatment begins to work. Your hospital can give you a certificate to refrain from work for your employers or the Department of Social Security, so you can claim sickness benefit if you are entitled to it
In the first week it is important to avoid pain killers which fall into the NSAID group such as ibuprofen. The preferred painkiller is paracetamol and you should refrain from drinking alcohol until the levels have fallen to a non-pregnant state.

What are the risks of being managed like this?

The main risk associated with treating you medically is that the medicine will not work and the cells of the ectopic pregnancy might continue to divide, which could result in there still being a need for surgery. Around 15% of women who are treated with methotrexate initially go on to need medical or surgical treatment. Doctors can tell if the specialised cells of a pregnancy that produce the hCG hormone are dividing because the hCG level will rise and not fall. Occasionally an ectopic pregnancy can rupture despite low hCG levels. If you are concerned about your level of pain, please contact your hospital.

What are the side effects?

Sometimes you may notice some mild to moderate abdominal pain. This tends to occur on day 3 or 4 after treatment. Many people feel very tired and are shocked by the sheer exhaustion that they encounter. Other occasional side effects (affecting up to 15% of patients) include nausea, indigestion, diarrhoea and sore mouth. Very occasionally, changes in the blood count, liver and kidney function may occur, but these are usually temporary.

How successful is it?

Success rates do vary depending on the circumstances in which methotrexate is given. Studies report success rates of 65-95%. Success rates tend to be higher with lower serum hCG levels. Your doctor should be able to tell you the success rate of methotrexate in their unit. Methotrexate is at least as good as surgery in terms of subsequent successful pregnancies. This may be due to the fact that medical treatment is non-invasive, whereas surgery may cause some scarring around the tube.

How will I know if theres problem and I need a different treatment?

Your doctors will be able to tell if your pregnancy isnt resolving, as this will be shown in the results of the regular blood tests. If this is the case, they will usually suggest surgery for you. A description of the signs of a deteriorating ectopic pregnancy, which include severely increased pain levels, vaginal bleeding, shortness of breath and pain in the tip of the shoulder, among others, which will alert you to the fact that you need to be reassessed, can be located here.

Your hospital should have given you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the accident and emergency department. If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or NHS Direct on 0845 46 47.

What precautions must I take for the future?

All women who suffer ectopic pregnancy are advised to avoid becoming pregnant for at least two proper period cycles, which is normally about three months. This is particularly important if you have been treated with methotrexate. This is because the methotrexate may have reduced the level of folate in your body which is needed to ensure a baby develops healthily. For example, it could result in a greater chance of the baby having a neural tube defect such as hare lip, cleft palate, or even spina bifida or other NT defects. The drug is metabolised quickly but can affect the quality of your cells, including those of your eggs and the quality of your blood for up to 3 or 4 months after it has been given. The medicine can also affect the way your liver works and so you need to give your body time to recover properly before a new pregnancy is considered. The current advice is to take folic acid for several months before you conceive. You must not begin to take folic acid supplements until the hCG levels have fallen to below 5<mIU/mL. Once your blood hCG levels have dropped, if you wish to become pregnant again, you should recommence your folic acid supplements several weeks or months before you conceive.

Your emotions

Until your doctors are confident that your pregnancy is ended it can be difficult to think about the future or for your emotions to surface properly. Being managed medically can be a worrying time for any woman, and until your hCG levels drop, you may still feel pregnant. Being worried about whether the pregnancy is resolving is quite normal and that is why your doctors are checking your hCG levels. However, women often say they feel guilty that they want the pregnancy to be over when they are also grieving for the loss of their baby. It is important you remember that the ectopic pregnancy was not your fault and that there was nothing you could have done to prevent it happening. More information about emotions is discussed here.


Frequently Asked Questions on Methotrexate

At what stage in pregnancy can I have methotrexate?

Methotrexate is most effective in the earlier stages of pregnancy, usually when the hCG level is below 3000. The risk of rupture is higher in pregnancies with levels greater than this. However, in cornual ectopic pregnancy it is not unusual to try to treat with higher levels. With ectopic pregnancy, it is not really the stage of pregnancy (as in the number of weeks gestation), but the size of the ectopic, which can vary over the first few weeks depending on the rate of growth, that is important. For a more detailed understanding of when Methotrexate might be considered, both this protocol and the Greentop Guideline 21 might be helpful. More information about methotrexate can be found on our message forums.

How long should I expect to bleed after Methotrexate?

The response of women to treatment with methotrexate varies greatly. The bleeding is from the lining of the womb and is hormonally controlled. It will probably last a week or two, changing in colour from red to brown and diminishing. As long as it is not too heavy, and is not associated with pain, you should not worry. Some women report bleeding and spotting for up to six weeks.

What happens when you have the shot of Methotrexate? Does the baby stay in the tube or does it get expelled? How will I feel?

In an ectopic, there is often a pregnancy sac, but most often a foetus or baby as we would know it, is not developing. What Methotrexate does is prevent the trophoblast cells from dividing. Trophoblast cells are the invading cells of the pregnancy and those that form the afterbirth or placenta. It is these that rupture the tube, cause the pain and have the potential to cause internal bleeding to the mother. Once these cells no longer divide, the pregnancy is ended and the whole pregnancy sac, including any cells that might eventually have grown into a baby, is usually reabsorbed by the mother. This is normal and happens in many cases of miscarriage. You may feel pain after being given methotrexate but this is due to the pregnancy sac swelling and not due to effects on the baby. The tube, however, may remain blocked by the pregnancy tissue which can take some time to shrink. Occasionally it may not shrink and will leave a blockage in the tube, by way of a small cyst. However, the use of Methotrexate does not reduce the chances of successful future pregnancy, whatever the outcome in the affected tube.

Women sometimes find treatment with Methotrexate quite a long and drawn out process. This can feel frustrating but the outcome is often very successful and it is worth persevering with the wait involved for the hCG levels to drop, and the repeated blood tests, until that happens.

My hospital will not offer Methotrexate, although I think I should be eligible for that treatment. What should I do?

The decision ultimately lies with your medical team within the health authority you are under, but there is never any harm in making it clear what your wishes are and asking to be assessed by someone who does use Methotrexate.

The use of methotrexate for treatment of ectopic across the UK is still varied. It may be that in one authority they use it, in the next they dont. Its as plain a fact as that and one that unfortunately does not help you. The use of methotrexate is still being researched so is not always available. If you would like it to be considered as a treatment, you certainly are within your rights to ask to be referred to a centre of treatment where it is available. You should ask to be referred to a consultant within the Primary Care Trust who can assess your suitability for this kind of treatment or on to another treatment centre.

If you need any help with this you need to contact PALS at the hospital where you are being treated. They can help you locate an assessment or new consultant if you need to.

Why does HCG level go up after a methotrexate shot?

The action of methotrexate is not instantaneous  it takes a few days for the cells of the pregnancy to stop dividing . It is the rapid division of these specialised trophoblast cells which causes hCG to be produced.

When we use methotrexate as a treatment for ectopic pregnancy, we expect to see a rise in the hCG level on day four after it has been given because we know the cells will have continued to divide for two or three days after it was given. More importantly we want to see a drop of at least 15% on day seven and if not, this is when the doctors will consider a second dose or surgery.

Is it normal to be exhausted after Methotrexate?

The way Methotrexate works is to deplete the body of the essential vitamin it needs to replicate cells. Our bodies are replicating cells all the time. The action of Methotrexate in the way that it is given to manage ectopic pregnancy medically is short-acting, but it is common for our bodies to be working very hard to recover from the depletion of folacin, which it is responsible for. On or around day 4 following treatment, it is very normal to feel utterly exhausted and this is because the drug interferes with essential amino acids that give us energy as a side effect.

You really do need to take things gently in the first couple of weeks after treatment with Methotrexate.

Folacin or folic acid in the form we take it in by our diets and supplements is a B vitamin and it is one of the vitamins that give us energy. It is important not to take folic acid supplements after treatment with Methotrexate until the doctors have confirmed that our hCG levels have fallen to 5<mIU/mL or below.

Feeling exhausted is a common complaint of Methotrexate treatment.

What happens to my baby when ectopic is treated with methotrexate?

WARNING  this is a difficult issue and may be painful to read. It should first be said that in ectopic pregnancy, because the egg has implanted in the wrong place, it is unable to source a good blood supply. As a result the trophoblasts are trying to burrow in to the walls of the structure the egg is stuck in and all energy and growth is occurring there. This means that our babies are not growing and so for more than 90% of us in ectopic pregnancy our babies do not, and have ever had, a heartbeat.

Methotrexate is a folate antagonist. This means it causes an essential substance needed to help trophoblast cells to divide to be released from the body. The cells can no longer divide because this essential substance is missing.

It is at this point the pregnancy tissue stops dividing. What then happens to this tissue depends and varies with each woman.

The tissue can shrink and be reabsorbed by the body  this happens because it is our DNA and our cellular material in the first place and so the body just reuses its resources. However this reabsorption can take weeks and sometimes months to be complete. Alternatively, it can appear to block the tube and over weeks, months or sometimes years shrink to allow the tube some patency at a later date. The tissue can sit there or cause a blockage, which may permanently block the tube. Or the tissue can separate from the tubal wall and be passed in the blood which is flowing out of the uterine cavity into the vagina.

Some women report what some doctors call separation pain, but many do not.

The bleeding that follows an ectopic pregnancy treated with methotrexate can be very heavy and clotty and result in the passing of what we call a decidual cast. This decidual cast can cause confusion, and the women can mistake it for the tissue of her baby. The lining of the uterus when we are pregnant, other than that which is taken up by the placenta, is called the decidua. The appearance of the normal lining of the uterus by the presence and action of progesterone becomes decidualised. When an area of the decidua is shed we call it a decidual cast. It is thought to occur as a result of the lack of stability of the integrity of the lining and this lack of stability is because the hormones arent functioning properly in an ectopic pregnancy. The sudden drop in hormones can cause the material inside the uterus to be shed in layers  the material that is passed can be grey, pink or white as well as appear like a clot or dark or frank red blood. It is very unlikely that if a woman passes material like this it is her baby, but she will often mistake it for that.

Is there anything I should avoid after methotrexate?

It is important is that anyone treated with Methotrexate avoids alcohol, NSAID drugs such as Ibuprofen and folic acid (this would include multivitamin complexes where there is a folic acid element) while the treatment is working.

What are the side effects of Methotrexate?

Here are the most common side effects:
Abdominal pain. Cramping abdominal pain is the most common side effect, and it usually occurs during the first 2 to 3 days of treatment. Because abdominal pain is also a sign of a ruptured ectopic pregnancy, report any abdominal pain to your health professional.
Vaginal bleeding or spotting.
Nausea, vomiting, and indigestion.
Fatigue, lightheadedness, or dizziness.

Rare side effects from methotrexate treatment for ectopic pregnancy include:
Skin sensitivity to sunlight.
Inflammation of the membrane covering the eye.
Sore mouth and throat.
Temporary hair loss.
Severe low blood counts (bone marrow suppression).
Inflammation of the lung (pneumonitis).

Why should I avoid alcohol after methotrexate?

The reason that drinking alcohol is advised against is because Methotrexate is metabolised in the liver in a similar way to alcohol. It is known to alter liver enzymes in the short term and traces of the drug can be found in the liver up to 100 days after the last dose. Therefore if the liver is very stretched through having to work too hard, it can cause you to feel very ill especially during the first couple of weeks after your treatment. It could also potentially damage your liver, so these are all good reasons to hold off.


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