HT without meds - again

[chix]

Hi all,

 

Am curious about something. Have spoken with at least a dozen guys who have had a transplant and not one of them is using any meds - fin or minox. Just about all of them are in their late 30's/40's. So what I'm wondering is whether at this age your hairloss pattern is well established? Also is it worth doing an extra HT in future if you don't wnat to mess with meds? Some people seem to think so. Is it worth staying off the meds if your goal is maybe to fill up to the crown - will that be too unnatural if you proceed to a NW 6? I know a few forum members have also had transplants without meds. The transplant might not look that great as if u were on meds, but if u could afford an extra session, is it worth staying off the meds. Am curious, since alot of people seem to have done this without meds. Also, as an aside, any idea as to how many grafts will an average donor yield? Just curious.....

[mattj]

The transplant might not look that great as if u were on meds, but if u could afford an extra session, is it worth staying off the meds.

I don't agree with this.

 

Propecia can improve hair quality by increasing the hair shaft thickness of hairs which are miniaturizing. Add a hair transplant to the mix and it can be said that the meds have improved the overall appearance of your hair, but they haven't actually improved the transplant itself. You might not even need or achieve that sort of benefit from the meds anyway.

 

The main benefit of the medications is in maintaining hair or greatly slowing the progression of hairloss. In some cases re-growth can occur too. So the main way in which using meds factors into a HT is in extending the time between procedures, hopefully putting the need for further work way off into the future or delaying it indefinitely.

 

IMO it's not a good idea to just look at your financial situation, decide that you will be able to afford more procedures and then dismiss medications as unnecessary. Taking a pill every day (or every other day) is much easier than surgery.

 

But having said all that, as you've discovered, many men do have hair transplants without medication. Meds aren't totally essential, they're just a wise choice.

 

I bet it's the possible side effects that worry you. You'll find that most people who have been around the subject for a while will agree that you owe yourself a trial run at least, because chances are you'll do just fine on them.

[NEWHAIRPLEASE]

I have been using the meds very consistently for the last 9 months..I wanted to get in ONE full year on meds before my transplant in January, 2012. I can honestly say I think they have helped my hair dramatically! My remaining hair just looks much healthier.. It almost looks to me if I just have thin healthy hair...I can't wait to put a transplant on top of what I already have!

[mahhong]

I haven't had a HT but I did try finasteride on two occasions and, on both of them (the first 3 months, the second 6 weeks) ended up with moderate side effects that troubled me enough to stop. Whether these effects were genuine, psychosomatic or something else I don't know, but I would be very reluctant to make the meds part of my future routine because I don't want those sorts of effects again and would see the risk of them developing as too high.

 

I don't think meds are essential but, as mattj says, they are very useful. You have to remember the hair on your head, if you're balding, is constantly thinning until the follicle either stops producing hair or the hair is so fine and light as to be useless cosmetically. What finasteride does is slow this down and, in some cases, halt it for long periods at a time.

 

I am of the opinion personally that, long term (30+ years perhaps), men who have HTs on finasteride and men who have HTs without will end up in similar places with regards their hairloss. Finasteride does not stop balding indefinitely and the results vary in individuals. Some men report a great response 10 or 20 years after starting the drug, others say their hairloss is catching back up with them after maybe only 5 years. A very small percentage of men don't seem to have much response to the drug at all.

 

But I think the man who doesn't use meds will, at very least, absolutely have to commit to a long-term and perhaps more modest goal when it comes to hairloss restoration. That means being more conservative in their goals, committing to multiple procedures and understanding that hairloss may be more rapid without the medication to help stall it.

 

Another important factor that hasn't been discussed is miniaturized hair being compromised when you have a HT without meds. If you have a lot of miniaturized hair and you have a HT, there is a good chance that can cause shockloss around the transplant site and, if the hairs are already very weak, they may not come back at all. The worst case is that you transplant say 3000 hairs, and lose 5000 hairs in the process! Men on finasteride will encounter this problem much less.

 

With all that having been said I believe there are still men who don't take meds who, if they commit to the cause, can still have a great result. Look at it this way, how many very bald men only learn about transplants and meds when they've already lost their hair? Quite a few. There are some very notable examples on these forums! But, several procedures later they have great heads of hair. Most of them are taking meds to prevent further loss (if there was to be any) but, nevertheless, a lot of the damage has already been done.

 

You don't need to take finasteride to have a great result from HTs, but the default position would be that if you can tolerate it, you should. Why wouldn't you? It slows down hairloss, often makes miniaturized hairs healthier and thicker. Some men start taking it and end up not even needing an HT (best case scenario), or suddenly their 5000 graft plans get revised down to 2500.

 

For me personally I am not yet ready (financially or otherwise) for an HT, but will have to consider one without drugs. My family history and my own current loss would have me think that I'm heading towards a NW Va or VI in the future if I'm like my Dad or his Dad I may get away with NW V, but my Mum's Father was easily NWVI or VII (thankfully my hairloss has not expressed like his - he had less hair at 24 than I do at 28 and much more temple recession - not a guarantee but a positive indicator). I think I may be lucky enough to not experience drastic hairloss but it will be relatively progressive (I think), and it will require pretty much as many grafts over multiple surgeries as I could get most likely.

 

So, I'd say at least try the meds. Also, in response to your other question, I think about 6-8000 grafts is the average donor yield. Hair characteristics will also play a big part in the success of any future procedures - some men can make 2000 grafts look like 5000 grafts on other men!

 

Meds are not the be all and end all of the hairloss world but they can have a drastically positive effect on some men, and the thinking is if it's only popping a pill everyday, surely it's better than spending $x on another HT? But the other side of that coin is the success stories some men who don't take meds have experienced. It is possible to get through this without meds, but only in some cases, and only with the right goals and the emotional and financial dedication to see it through.

[corvettester]

I've been debating the exact same scenario.... There are just so many variables to consider that it's mind-boggling. To tell you the truth, the decision to start Propecia has been more difficult than my decision to undergo FUT.

 

 

Corvettester

Edited September 26, 2011 by corvettester

[zenmunk]

Been on propecia for 13 years, 1mg every day. Missed a few days, but not many. Pretty much halted my hair loss since the beginning of the regimen. No observable sides except slightly watery semen. I've been pretty lucky so far (and I'm thankful for it), but who knows how long the meds will keep my hair loss in check?

 

I am trying to decide if I should go forward with FUE (approximately 1300 grafts) to restore my hairline. Among my top considerations is what the propecia may be doing to my body in terms of non-observable side effects.

 

Every six months since I started the meds I've gotten some blood tests done to monitor the health of my liver; so far, so good. However, I don't believe that's enough. Before I go forward with a HT I'd like to try and find out as much as I can. So, I'm planning on doing the following:

 

1. Getting a semen analysis done.

2. Getting a testicular ultrasound done.

3. Getting a full spectrum hormone analysis done (saliva & blood)

4. Getting a prostate exam done.

 

If the results of those tests come back normal, then I will finish my HT research which involves one more in-person consultation with a HT doc and meeting as many of his FUE patients in-person as I can (with similar hair characteristics and hair loss to my own) to discuss their experiences and review their results.

 

If all of that works out, only then will I move forward with the HT. If the results of the above tests indicate some kind of problem(s) which can be traced back to the propecia, then I will most likely discontinue the meds (unless there is a relatively safe way to address the problems without discontinuing them). If I stop the meds, I don't think I will go forward with the HT, and rather shave down, as I do not want to chase my hair loss with surgery after surgery for the rest of my life. Personal choice.

 

HT is a serious matter on its own, but combining it with meds makes it much more so. The pros and cons must be carefully weighed. I'm in a good position to discover what, if anything, long-term propecia use has done to my body. I will keep this community informed. Everyone is different, but perhaps my results will be of some help to you all.

 

Corvettester is absolutely right - the considerations are mind boggling.

Edited September 26, 2011 by zenmunk

[hairthere]

Hey Chix, I just PMed you back. I stopped taking the meds because 1) I was trying to have a child, and 2) My hairloss had progressed so much I decided to just let nature take its course and replace it with HTs. I did not experience any sides with them.

[chix]

Hey guys - very insightful posts!! I totally agree with mattj and mahhong that meds, especially fin, will probably go a long way in helping you maintain and making healthy your existing hair as well as regrow some new hair. However, seeing the number of guys having had transplants and staying off meds, it begs the question as to whether they are totally ignorant of the meds or are conciously staying off them for the sides or whatever other reason. I guess another thing to consider is age - a guy in his early twenties probably needs to get on to meds to help slow down/stabilize the baldness. However, older guys, who have already lost a lot of hair over the years can probably get by. I guess this is true only if you're transplanting into a totally bald area where meds will not affect the DHT resistent hair. I've seen severely bald guys looking amazing after a transplant where the meds are not required for the transplanted hair. However, fin will definitely help preserve the hair above the safe zone as well as keep the donor area healthy. Again, the anectodal evidence regarding severe and persistent side effects of fin continue to mount and I wonder if young guys are playing russian roulette with their bodies by continuing on fin for an unlimited period of time. Sure, there are tons of guys who don't experience sides or overcome them but then the long term efficacy of the drug is still largely unknown. Having said that, there is no doubt that fin helps in slowing down hairloss but its a tough choice to make. I agree with Corvettester - the considerations are mind boggling with too many uncertain variables. If you choose not to take fin, IMO its better to settle for modest goals and be satisfied with that, coz from what I can tell, guys are still struggling with this question. Zenmunk will definitely be doing the whole community a huge service by keeping us informed of his results, although I suspect after 13 years of being on fin and experiencing few, if any sides, all should be well. But how many guys are as diligent as he is? and that too on a continual basis? Can't think of too many people monitoring their livers every 6 months!

 

hairthere - thanks for your PM. Much appreciated! I PM'ed you back with some more thoughts, i'd love your opinion on.

[mahhong]

Hey guys - very insightful posts!! I totally agree with mattj and mahhong that meds, especially fin, will probably go a long way in helping you maintain and making healthy your existing hair as well as regrow some new hair. However, seeing the number of guys having had transplants and staying off meds, it begs the question as to whether they are totally ignorant of the meds or are conciously staying off them for the sides or whatever other reason. I guess another thing to consider is age - a guy in his early twenties probably needs to get on to meds to help slow down/stabilize the baldness. However, older guys, who have already lost a lot of hair over the years can probably get by. I guess this is true only if you're transplanting into a totally bald area where meds will not affect the DHT resistent hair. I've seen severely bald guys looking amazing after a transplant where the meds are not required for the transplanted hair. However, fin will definitely help preserve the hair above the safe zone as well as keep the donor area healthy. Again, the anectodal evidence regarding severe and persistent side effects of fin continue to mount and I wonder if young guys are playing russian roulette with their bodies by continuing on fin for an unlimited period of time. Sure, there are tons of guys who don't experience sides or overcome them but then the long term efficacy of the drug is still largely unknown. Having said that, there is no doubt that fin helps in slowing down hairloss but its a tough choice to make. I agree with Corvettester - the considerations are mind boggling with too many uncertain variables. If you choose not to take fin, IMO its better to settle for modest goals and be satisfied with that, coz from what I can tell, guys are still struggling with this question. Zenmunk will definitely be doing the whole community a huge service by keeping us informed of his results, although I suspect after 13 years of being on fin and experiencing few, if any sides, all should be well. But how many guys are as diligent as he is? and that too on a continual basis? Can't think of too many people monitoring their livers every 6 months!

 

hairthere - thanks for your PM. Much appreciated! I PM'ed you back with some more thoughts, i'd love your opinion on.

 

I think fin is ultimately a very safe and usable drug for the vast majority of men, but this is a good post. My major concern after experiencing sides was really the fact that this was a lifelong commitment.

 

You have to take fin for the rest of your life if you want to maintain any results you're having with it. Whilst I don't think taking fin is "playing with fire" by any means, I do think as you and your body change the older you get, it is difficult to know if or how the continued dosage of fin will affect you. I am not a scientist or even particularly informed on this subject, but to me it stands to reason that if you continue taking a drug over the course of decades then you should really monitor as effectively as possible if you have any issues with it.

 

The other massive factor is starting a family. The vast majority of literature states that it's safe to take fin whilst trying to conceive (so long as the mother doesn't come into contact with the pill itself) but I think most men would find it a risk not worth taking. When there is another life potentially involved no matter how small the risk it just seems a bit foolish to be taking the drug. And I'd hate to take fin in my 30s and maybe late 30s be with a woman I love, decide to start a family, and then stop the drug and see the effects just evaporate (not to mention the money and time I spent on the drug).

 

Long term efficacy, as chix says, is also still an issue for me. I know all the literature points to the drug being safe and fine to take indefinitely, but we just don't have men who have been on the drug for 40 or 50 years alive yet to verify they've been fine.

 

Also, the type of person I am, I know if I was to ever suffer with ED or sexual problems later down the line, I would have a hard time not feeling guilty about fin if I was taking it. My logical mind knows you're more likely to get ED from just getting older or other health or lifestyle problems but, well, I don't want to be worrying about my hair AND worrying about the medication I'm taking for it!

 

I think most men who take fin feel just fine and look at the "problem" of taking the drug as a non-issue for them. Similarly most men who have yet to start see it as quite a big hurdle to climb. I couldn't tolerate the drug physically anyway but even if I could I'd have constant reservations about whether it was the right thing to be doing anyway. And I just mean right thing for me - knowing myself and knowing the drug.

 

I think zenmunk's rigorous health check-up is a good idea, even if it seems a bit full on for some. I'm not into conspiracies or hyping things up but, whilst I believe fin is probably safe for most men, there is no doubt the jury is still out over exactly what the drug does over the course of a lifetime. And with men as young as 18 or 19 getting on it I just wonder whether potentially 60 or 70 years taking a hormone-changing drug for the sake of your hair is worth it with so many long-term variables ultimately poorly understood.

[zenmunk]

Zenmunk will definitely be doing the whole community a huge service by keeping us informed of his results, although I suspect after 13 years of being on fin and experiencing few, if any sides, all should be well. But how many guys are as diligent as he is? and that too on a continual basis? Can't think of too many people monitoring their livers every 6 months!

 

Certainly hope you're right, chix. I'd love to report to you guys that everything is OK. I really didn't like the idea of going on the meds back in '98, so the only way I would allow myself to do it is to commit to the blood tests every six months to monitor liver function and pay close attention to observable sides.

 

My major concern after experiencing sides was really the fact that this was a lifelong commitment.

 

I certainly believe going the HT route w/o meds is a viable option, but it's not for me. If I get the FUE done, then I'm basically committing to the meds until 1) a health issue forces me to stop, or 2) the meds stop working for me. The thought of a lifelong (or indefinitely long) commitment to the meds is daunting. I like the idea of being able to stop the meds anytime I want; the option is comforting. However, the thought of restoring my hairline and continuing to maintain my native hair with the help of the meds is quite seductive.

 

What if 1) or 2) occur after I've gotten the HT? That keeps me up at night. The only solution I've been able to come up with is go the FUE route, make sure the smallest possible punches are used (safely of course) and insist that the extraction pattern be spread out as much as possible, throughout the entire safe zone (sides and back) and beyond (I'd sign something giving my doc permission to do it). The hope is that approach would minimize the appearance of white dot scarring and spread out donor thinning as much as possible. Then, if the meds eventually fail me, shave down and use copious amounts of ridiculously high SPF sunblock to keep the tan contrast between the scars and scalp at bay. It's an imperfect plan, but the best I've come up with so far.

 

Or, maybe say %&$# it(!), forget the HT, ditch the meds and shave down! I must admit, some part of me would just love to do that and let all of this worry go... But then, one worry gets replaced with another. A good friend of mine is a Norwood VII and has been shaving down for many years. He says he wishes there was a way to have his remaining donor hair permanently removed so he doesn't have to shave everyday. He was even looking into some kind of laser treatment. There's no easy way to address hair loss. Pick your poison.

 

The other massive factor is starting a family. The vast majority of literature states that it's safe to take fin whilst trying to conceive (so long as the mother doesn't come into contact with the pill itself) but I think most men would find it a risk not worth taking. When there is another life potentially involved no matter how small the risk it just seems a bit foolish to be taking the drug.

 

I'm getting a semen analysis to make sure everything is healthy regarding fertility issues. Finasteride exposure is a trickier subject.

 

Merck states that a pregnant woman's contact with the semen of a man taking finasteride is not an issue for concern.

 

The FDA info on Finasteride states:

 

In 2 studies of healthy subjects receiving Finasteride 5 mg/day for 6 to 24 weeks, Finasteride concentrations in semen ranged from undetectable (< 0.1 ng/mL) to 10.54 ng/mL. In an earlier study using a less sensitive assay, Finasteride concentrations in the semen of 16 subjects receiving Finasteride 5 mg/day ranged from undetectable (< 1.0 ng/mL) to 21 ng/mL. Thus, based on a 5 mL ejaculate volume, the amount of Finasteride in semen was estimated to be 50 to 100 fold less than the dose of Finasteride (5 mcg) that had no effect on circulating DHT levels in men.

The FDA info on Finasteride also states:

 

Intravenous administration of Finasteride to pregnant monkeys at doses as high as 800 ng/day (estimated maximal blood concentration of 1.86 ng/mL or about 143 times the highest estimated exposure of pregnant women to Finasteride from semen of men taking 5 mg/day) resulted in no abnormalities in male fetuses.

 

The Merck and FDA statements notwithstanding, the facts that probably millions of men worldwide have fathered healthy children without discontinuing finasteride use & there are no major news stores decrying finasteride-related birth defects are pretty strong evidence that the odds of a male fetus having developmental problems because of the amount of finasteride in the father's semen are infinitesimal (Of course, a pregnant woman ingesting or handling broken finasteride tablets is another story altogether).

 

However, if one believes it's unwise to be on meds while trying to conceive, then the question is: how long before conception should a man discontinue the use of finasteride? I haven't been able to find a definitive answer to this question.

 

Some subscribe to the half-life approach. Dr. Rassman states:

Some sources say finasteride half life is 4-5 hours. Some say it is 8 hours. My Epocrates drug database says it is 6 hours. Half life is the time it takes for 50% of the drug to be out of your bloodstream. So if you assume that the half life is 6 hours, then most of the medication should be out of your bloodstream and excreted out of your body in a day or so (it is excreted in your feces and urine). But being out of the bloodstream does not always correlate with it being out of your body per se, because some form of the medication is left in your tissue.

 

If we go by the half-life approach, finasteride is probably out of most men's bloodstreams after 7 - 10 days of discontinuing use. If a woman is most fertile approximately 4 days per month, a man could stop the meds 7 - 10 days prior to starting efforts to conceive, then spend the fertile 4 - 7 days trying to conceive. That would mean he'd be off of the meds for approximately two weeks. Two weeks is a snap - no hair loss and no risk to the fetus (as long as the man wears a condom during sex for the duration of the pregnancy). Great, end of story, or maybe not...

 

The sperm production cycle may confound the half-life approach. The sperm production cycle is 90 days. Sperm are produced in the testicle and take about 90 days to reach full maturity. After the sperm have been produced, immature sperm are deposited in a receptacle called the epididymis. There, the sperm continue to mature and develop their “swimming” ability until ejaculation. If one took finasteride within the 90 days prior to stopping for 7 - 10 days for conception purposes, the sperm one produced will probably still contain or be affected by finasteride despite stopping for 7 - 10 days. How much will remain after stopping for 7 - 10 days is anyone's guess. Would stopping for 7 - 10 days reduce the chances of developmental problems in a fetus? Who knows? I plan to ask a urologist about this...

 

Regardless, it's clear that if one wants to be 100% sure that there will be no finasteride in one's semen, then there's no choice but to discontinue finasteride use at least 3 months prior to conception and risk losing some amount of the hair maintained while on the meds.

 

I think zenmunk's rigorous health check-up is a good idea, even if it seems a bit full on for some. I'm not into conspiracies or hyping things up but, whilst I believe fin is probably safe for most men, there is no doubt the jury is still out over exactly what the drug does over the course of a lifetime. And with men as young as 18 or 19 getting on it I just wonder whether potentially 60 or 70 years taking a hormone-changing drug for the sake of your hair is worth it with so many long-term variables ultimately poorly understood.

 

I appreciate that mahhong. For the record, I'm not an alarmist or hypo(cyber)chondriac (I realize you're not suggesting I am in your statement). I simply realize that finasteride is a powerful drug, and I've been on it for a long time. Before I get a HT, and commit to the meds indefinitely, to whatever degree possible, I must make sure the propecia is not hurting my health in areas most commonly reported.

Edited October 2, 2011 by zenmunk

[Jotronic]

One thing that never made sense to me is the idea, and that it is is a hurdle, that taking Fin daily is a lifelong commitment. Well, I'm here to tell you fellas that surgery in and of itself is a lifelong commitment if you are not on Fin ( and sometimes when one is on Fin) simply because hair loss is progressive, does not stop, and will get worse. Period, end of story.

 

Taking Fin daily is a commitment but so is brushing your teeth. Stop brushing your teeth and your teeth will rot. Stop using Fin (or don't start to begin with) and your hair will rot. Simple as that. The sides are something that if they do affect you, and the chances are that they won't, then cut back to every other day and you should be fine. If you opt to just stop then so be it but I give NO credit to the claim that sides are permanent especially when fin washes out of one's system in a matter of days. I'm fully of the opinion that the mind plays tricks on us more than we think especially with the subject of the efficacy of one's sexual prowess and abilities.

[aaron1234]

Ditto Joe. And zenmunk that was one heck of a write up! I've always wrestled with whether I should stay on Fin if trying to conceive in the future.

[mahhong]

Lots of interesting thoughts on this thread!

 

I am somewhat biased because I took fin and did feel it was messing with my sexual prowess to a noticeable degree. I do not discount that this could have been psychological, but it didn't feel that way and I'm not prone to worry about medicine in that way. I did mess with dosages a bit (possibly not as much as I could have done) but on both occasions felt there were physical effects that were beyond what I would tolerate and that these weren't acceptable to me.

 

I would counter a little bit the idea that finasteride is like brushing your teeth. It's not a "commitment" in the sense that it takes time or energy or anything like that, most certainly. But it is a drug that alters your physiology on a permanent basis (whilst you're taking the drug) and, to that extent, you do have to commit to actually doing something to your body every day. To those who experience no effects then it may as well be like brushing your teeth but, ultimately, this is not about cleaning your canines! This is a body altering drug - even if the only alteration you notice is more hair.

 

As I say, I don't necessarily feel that trying to conceive whilst on finasteride is a bad idea - the literature certainly doesn't support that idea. And zenmunk is absolutely right that millions of men have likely fathered children whilst on the drug and there have been to my knowledge no reports of birth defects - certainly nothing linked explicitly with finasteride.

[zenmunk]

It is important to stress that HT is a cosmetic procedure. It's elective, as is taking finasteride in doses, and on a schedule, appropriate for hair loss. No one here has to do it for health reasons, hygienic or otherwise. We choose to do it.

 

As someone who has taken the drug and tolerated it well (as far as I can tell) for many years, I still believe people are justified in their concerns about the possible side effects of finasteride, both short and long-term. No one can say with certainty that the drug is not causing serious damage on levels which are hard to detect. I won't be certain even after I get the tests done, but I'll be a lot closer to certain, and that'll have to be good enough if I choose to remain on the meds for the long-term.

 

Some people can shrug off the concerns quickly. Others need to do more research or testing or what-have-you to be confident that it's a risk worth taking. Life involves prioritizing and assuming risks. Can't escape it, but we can try to make the most educated guesses.

 

Ultimately, it's a personal choice - whatever works for you - but regardless of what one's position is regarding taking medications to prevent hair loss, it should not be taken lightly. Just as getting a HT demands a lot of time, serious thought and research, so does starting on meds.

[biscuit]

Another major consideration is your baldness pattern. It's not uncommon to see older guys with a strong horeshoe of donor hair but a bald forehead. Meds aren't going to help much in that scenario.

 

In my case I lost the hair on the front half of my head by the time I turned 40, but my donor was(is) thick and strong. My family members have very little donor thinning. So for me I wasn't worried about diffuse thinning. All I needed to do was move some hair up front.

 

My single-pass HT is holding strong at 6 years post-op and I've never taken any meds. So it's a case-by-case decision. But there is definitely a category of patients who have less need for meds.

[multiplier]

I'm fully of the opinion that the mind plays tricks on us more than we think especially with the subject of the efficacy of one's sexual prowess and abilities.

 

I'm coming around to this idea myself.

 

I say that because after taking Propecia every day for these past 12 years, only this year did I suddenly experience sexual side-effects throughout 2011. But on top of that was extreme stress (collapsing sex life, divorce, high-profile job, tight finances, living in NYC, bailing out of NYC) which, psychologically, cut my libido in half and caused tightness of the penis and urethra - worrisomely similar to Propecia's side effects.

 

So after reading the horror stories, I became obsessed that it was Propecia causing my issues, even though multiple top urologists and endocrinologists told me it was likely stress-induced prostatitis.