Thoughtful Thursday: Down the Line

Perhaps the biggest kick in the ass about my breastfeeding troubles was the realization that the effects of infertility might be so long-reaching. I don’t know whether the unknown cause of our infertility contributed to my breastfeeding problems, or whether they were only due to the half a dozen other factors at play. You’d think that after all of the struggle to get pregnant, the rest of it should be easy. You’d think that, but that’s not how things work. Some people get more than their share of difficulty, either through random luck or because everything has the same common cause.

Have you worried that infertility treatment, or infertility itself, would cause problems down the line?

Aside from breastfeeding, the ability to carry a pregnancy is another area where infertility can extend its clammy paw. For some women, the same factors that made it difficult for them to get pregnant will also make it difficult to carry a pregnancy to term successfully. The kicker for them is that they often don’t realize the connection until after one or more pregnancies have been lost or cut short.

The biological causes of infertility can also impact the health of the children, sometimes right away and sometimes in terms of future fertility. We discussed the worry over passing along our infertility in a Thoughtful Thursday over a year ago. There are also some causes of infertility that can be passed on to the immediate detriment of the child’s health; clotting disorders and cystic fibrosis genes are two that come to mind, but I know there are many others. In the short term, even when the cause itself isn’t transmitted genetically, biological problems that had caused infertility and also lead to prematurity can obviously impact the baby.

Then there are problems that most of us prefer not to think about: side effects of treatments. Some of us do as many treatments as it takes to achieve our goals, consequences be damned. Others try to minimize the level of exposure to drugs or interventions out of concern for potential long-term side effects. Of course we all hope that all of those injections won’t cause a serious problem in the future, but personally for me that hope was far overshadowed by all of my short-term hopes that the injections would create a baby. I pretty much stuck my fingers in my ears and sang LA-LA-LA-LA-LA. My husband was actually the one who was more concerned about the drugs causing me damage — not enough to even consider putting the brakes on anything, but enough to raise the issue with a furrowed brow. Eleven was the number of treatment cycles that it took me to achieve a successful pregnancy. Will 11 end up being not enough to do permanent damage, or just enough? LA-LA-LA-LA-LA.

Have you worried that infertility treatment, or infertility itself, would cause problems down the line?

What I Wish I’d Known About Breastfeeding, Part 2

Continuing the breastfeeding discussion we started last week when we discussed risk factors…

When we left off, I had insufficient supply, and the babies didn’t know how to nurse because they were born too early. I was pumping all day for a small amount of milk, but most of the twins’ nutrition came from formula.

I tried all sorts of tactics to make breastfeeding go better, including:

• Consultation with lactation consultants (LCs) in the hospital. I saw half a dozen different LCs when the twins and I were in the hospital, some on the post-partum unit and some in the NICU. Despite having had many visits from many people, I feel like they failed us. We left the hospital with neither baby able to nurse without a nipple shield, and with me having little idea how to help them nurse nor do basic skills like breast massage. In terms of the latter, I asked an LC to show me, and she demonstrated in a very cursory way on her own breasts. As a result, for weeks afterward I was massaging in a wrong and totally useless way.
• Consultation with an LC at home. We had several sessions with a nurse home visitor who happened to be an LC. She helped us a bit and made some suggestions like fenugreek to improve supply, but we still didn’t learn to nurse.
• Pumping to increase supply. This started the day the twins were born, probably about 9 hours after birth. They weren’t able to feed by mouth for more than a week, so pumping was the only option. I was told to pump at least 8 times per day, but I was also told that because of my severe blood loss, it was more important that I rest. I did my best reconciling this conflicting advice. Usually, rest won.
• Fenugreek. This made more difference than anything else I tried. I ended up on quite high doses since the lower doses didn’t do much.
• Domperidone. For dumb reasons having to do with the FDA’s misinterpretation of outdated findings, it is very difficult to obtain domperidone in the U.S. I used an international supplier. This helped me somewhat. Note that I did not take reglan because I was already struggling with enough postpartum mood issues and didn’t want to risk the side effects. Domperidone was also appealing because it does not cross the blood-brain barrier as reglan does. I worked up to the recommended dose but ended up upping my dose several times to a much higher alternate maximum recommended dose because the lower doses ceased to be effective.
• Pumping techniques to encourage supply. I power-pumped at various intervals. I kept the pump on stimulation mode until let-down occurred (which always took a long time for me). I turned the dial as high as I could stand it.
• Chiropractic. I actually started seeing the chiropractor for a different problem resulting from my months on bedrest, but The Breastfeeding Mother’s Guide to Making More Milk said that it could help. I don’t know whether it helped the milk supply, but it did help my other issues.
• Massage. Massaging two specific acupuncture points related to let-down helped quite a bit. My massage therapist worked on them when I saw her, and I often massaged them myself at home (or got DH to do it).
• Relaxation. There were long periods when I would cry every time I pumped, so relaxation was not so easy for a long time. It got better.
• Food and liquid intake. Some people say that you need adequate food and lots of fluids to produce milk. Some people say it doesn’t matter. I don’t know the truth, so I made a big effort to get enough, even instructing visiting family to tend to my intake as part of their baby duties.
• Edited to add: Oatmeal. Eating oats seemed to increase supply a bit, at least for a little while. When I got sick of eating oatmeal, I became a fan of yogurt with maple syrup and lots of rolled oats stirred in.
• Consultation with one more LC. After four months of misery, I decided to give it one last shot. I asked our pediatrician if he knew a great LC (because I was fed up with mediocre ones). He sent me to the head of his hospital’s lactation department — a different hospital from where I delivered. She helped me figure out that the babies had permanently lost the ability to nurse. She was outraged that the LCs at the other hospital had sent us home with the twins not knowing how to nurse, and she said that our situation made her sad. That really touched me. She encouraged me to exclusively pump as long as I could manage, but to feel free to stop when I needed to for the sake of enjoying being with my babies. Unlike most LCs I’ve encountered, whom I’ve found dogmatic, she was committed to doing what was best for us, not just committed to breastfeeding. She also reinforced what a fantastic job the obstetricians did during our birth at saving my life and my uterus — from what she’s seen, it’s rare to have such a good outcome in a situation like ours. Milk supply problems are a small price to pay compared to what could have happened.

Despite trying all of these strategies, there are so many things I wish I’d done differently.

• Insisted on pumping immediately after birth. It did not occur to me to pump in recovery while I was twiddling my thumbs. As soon as I got to the postpartum unit I requested a pump, but it did not arrive for hours.
• Insisted on more active help from LCs. I knew that they weren’t doing much, and I knew that I needed more help, but it seemed like asking for help on a daily basis should have been enough.
• Pumped more in the first few weeks. This is a biggie. The Breastfeeding Mother’s Guide to Making More Milk said that supply is calibrated based on the demands in the first 2 to 3 weeks. I really wish someone had told me this!! Because I was producing so little, I got discouraged and didn’t feel like there was much point. I pumped as often as was convenient, but not nearly as often as I could have. No one ever said that the point of pumping in the early days was not to produce milk now, but to teach the body to produce milk in the future.
• Not taken the LCs’ instructions so literally. In the hospital they said to pump every two hours. When I left they said that every two hours was not tenable, and I should pump every three hours. In my compromised state, I took these instructions very literally. If it had been 2 hours and 40 minutes since the last pumping and both babies were asleep, I waited 20 minutes to pump again; invariably, one or both babies would wake up and turn 3 hours into 4 or 5. I should have pumped whenever I had the chance instead of watching the clock. It seems so dumb and obvious now, but sticking to the time screwed me multiple times a day.
• Found an expert LC quickly. I had a list of experts in low supply from The Breastfeeding Mother’s Guide to Making More Milk, but none of them were in my area. Because I’d had such unimpressive interactions with so many LCs, I didn’t trust that anyone out there could help me. I was not enthusiastic at the idea of seeking out someone (or a few people), paying them a lot of money, and then being disappointed. It turned out that the LC at our pediatrician’s hospital was free.
• Read The Breastfeeding Mother’s Guide to Making More Milk earlier. I didn’t know it existed, so this isn’t a regret as much as a retrospective wish. In addition to the suggestions, having a better understanding of the lactation process really would have helped me, as would the encouragement the book provides.
• Seen more doctors. I saw OBs at the scheduled intervals for postpartum follow-up, but I didn’t mention anything about breastfeeding at my 2 week checkup because I was waiting for my milk to kick in. By the 6 week appointment, the situation felt desperate and I was forlorn. Seeing an OB, or even a PCP between 2 and 6 weeks might have done something.
• Tried harder at direct breastfeeding. I was in a quandry because I had so little supply that it seemed pointless to have the babies nurse, especially given that nursing was a struggle for them and for me. However, it is possible that proper stimulation by the babies in the first weeks would have increased supply. Being fair to myself, though, I don’t know if I could have handled more. Burrito in particular had a very hard time at the breast, and his rearing and fighting really aggravated my preexisting repetitive stress injury in my wrist. I also got very frustrated when I would nurse them both and then they would each take as much in their supplemental bottles as they would have eaten if they hadn’t nursed at all. After a couple of months of mostly pumping with a couple of attempts at nursing each day, I made a conscious choice to pump exclusively. It felt better to know exactly how much they were taking in (at best, a couple of ounces per baby per day, with formula making up the difference), because I didn’t feel comfortable with my preemies taking in an unknowable amount of milk from the breast. I hoped that I could increase supply further with drugs and other tactics and then maybe go back to nursing — which I now know probably wouldn’t have worked.

I have more regrets about breastfeeding than about probably anything else in my whole life. What’s most frustrating is that despite my many regrets, there’s a very good chance that nothing I could have done would have made a difference. The most consistent thing I ever heard from health professionals, from LCs to obstetricians to neonatologists to nurses, is that because of the extent of my blood loss during delivery, there was little chance that nursing would ever work for us. Add to that the preemies who didn’t know how to nurse, and the prematurity meaning that the last 6 1/2 weeks of breast preparation didn’t happen, and the c-section, and the possible influence of endocrine issues and infertility, and it’s quite clear to me now that we were pretty doomed.

I have so many regrets about breastfeeding, but at the same time I have to feel proud of myself. I have truly never tried so hard at anything in my entire life. Many people asked me what the point was, or why I was trying so hard. I have seen the data on the benefits of breastfeeding, and I find the data compelling. Particularly for preemies, there were too many benefits not to do my best. I feel good about providing what I could for them. They are so healthy and big now. I worked hard at bedrest before they were born to get them here, and I worked even harder after they were born at making milk. My love for them is astronomical, and contributing to their well-being was one way that I wanted to show my love.

Paradoxically, by showing my love for the twins in this way, I cost them love in other ways. So many hours each day were spent pumping alone, and more time almost every day was spent crying or otherwise upset. Too much of the time in their first months they got a mother who was preoccupied with breastfeeding, instead of a mother who was marveling at their wondrousness. The same way that pregnant women and babies used to make me sad during my years of infertility, now it makes me sad to see nursing mothers, as well as mothers who could but choose not to nurse. Infertiles are still my peeps, but now those who struggle with breastfeeding are also my compadres. I feel doubly connected to those who belong to both clubs, and so very sorry that the joy that we anticipated for so long has to be dampened by our bodies failing us yet again.

I’m almost done weaning from the pump now. It’s liberating, but it’s also scary. Many times I’ve panicked and wondered if I’m making a huge mistake — because there’s no going back. Relactation is hard enough for mothers who had nursed successfully; I can’t imagine that it would go well for me. I’ve also had crazy thoughts of having another baby just for the sake of breastfeeding successfully. I’m trying to find peace with it all, and the best way I know to find that peace is to blog about it and hopefully help someone else avoid what I’ve gone through. I’ve sobbed all the way through writing this post, and I just need to hit Publish and be done with it, but if there’s anything I’ve left out, or anything anyone wants to know, please ask.

Thoughtful Thursday: Hiatus

Slate is running a series of articles from a man who will be giving up the Internet for the next four months (so far you can read part 1, and part 2).

My first thought: Gaaaaah!

Could you live without the Internet? If you wanted to cut down, what could you give up?

I literally cannot function without the Internet. For one aspect of one of my jobs, I am contractually obligated to go online and deal with certain things at least once per day. In other areas of my work, I collaborate with people around the world, and emails and shared files are essential. For work that I do independently, I often need to log into the VPN server to run software.

Outside of work,

Before I was contractually obligated to go online every day, I did have some individual days where I didn’t go online, usually when I was traveling. It was kind of nice to be temporarily unplugged, but only because I knew that I could resume in a day or two. Sometimes, my online absence resulted in a “Where are you?!?” shitstorm.

At times, especially since giving birth, I’ve gone without checking one of my work email accounts for several days. As each additional day passed, it went from being liberating to anxiety-inducing. Were there angry emails waiting for me? New tasks to add to my already overwhelming list? Sometimes, when I’d finally muster the courage to check the account, my fears would be realized. Other times, there would be nothing. It’s a relief not to have demands placed on you when you’re not looking, but it’s also humbling — the world can function without me, at least some of the time.

Outside of work, there are my personal pursuits. I don’t need to write blog posts, read blog posts, or maintain personal correspondence. I don’t need to, but I sorta do need to. This is an area where I can cut down when necessary, but I really like to post as much as I can on my various blogs and I like to keep up with others’ personal blogs as well as news-type websites. As for email, there are some relationships where email is our only form of communication. As sketchy a correspondent as I can be, some of my friends are far worse, and we would cease to talk altogether if we had to rely on the phone or (haha) hand-written letters.

Then there’s the online shopping. Except for food, almost everything that we buy comes from the Internet. I guess I could shop in stores, but I haven’t yet mastered shopping with two babies.

I don’t even know that I can go a whole day anymore without communicating with my own husband online. Throughout the day as he’s locked in his office upstairs, I send him emails or instant messages to say hello, request help with a baby, or do the kind of nuts and bolts communication that most couples probably do face to face. “Did you pay this bill?” “Where is this thing?” “What do you want for dinner?” I suppose that I could resort to the phone or, (gasp!) going upstairs.

Normally, I could live without the Internet for a day or two, but no more. Now, because of work, I can’t even go one day. Oh, modern world.

Could you live without the Internet? If you wanted to cut down, what could you give up?

What I Wish I’d Known About Breastfeeding, Part 1

(Note: Discusses babies, pregnancy, and postpartum issues, but also discusses the biological aftermath of infertility. If you’re not in the mental place to read it now, perhaps file it away for the future. I sure wish I’d had a post like this. If you could have used it earlier, I’m sorry — I’ve wanted to write about this for so long, to help others and to process it myself, and I’ve had this post half-written for half of my babies’ lives, but it was always too painful to keep working on it. I’m finally ready.)

I had no idea.

I had no idea that breastfeeding would be my Achilles heel. I actually have Achilles tendonitis right now as a result of the months on bedrest, and it’s nothing compared to the tsuris of breastfeeding.

There are so many things I didn’t know, even though I thought I was prepared ahead of time. I read Mothering Multiples cover to cover, and it seemed doable. I trusted that the lactation counselors in the hospital would help us with anything that the book didn’t cover.

I was so wrong.

My preemies started on IV nutrition then nasogastric tubes, and once they were put to the breast they didn’t yet know how to suck. I couldn’t even hold my daughter for the first day of her life, much less nurse them right after birth as is recommended. In the just over two weeks the babies were in the hospital, my supply was low but some LCs and doctors thought it might increase over time. Given my more than 6 units lost due to hemorrhaging during delivery, the general feeling was, “Of course you don’t have much milk. You barely have any blood left.” Some ‘experts’ said it might get better, and some said it never would. I tried not to listen to the latter group.

My low supply continued, and continued, and continued, and meanwhile my babies still didn’t really know how to nurse. Meanwhile my postpartum hormones were all over the place, and much of the time I couldn’t stop crying. Nursing went horribly almost every time, and I barely had anything to give them anyway, so eventually I decided to focus on supply and pump rather than nursing. This meant that literally most of my waking hours were spent either feeding a baby or pumping. Sometimes I didn’t have enough help from others and had to postpone pumping to care for the babies, which invariably sent me into a panic. Other times, my husband or visiting family or friends took over the baby duties, meaning that I was locked alone in a room with my pump while other people got to be with my babies. I also had to schedule my life around the pump, and most activities outside the house were out of bounds because they didn’t fit into my pumping schedule. For the most part, we barely left the house, which in retrospect wasn’t good for any of us.

There were many low points, but one of the lowest came during a rare time I left the house. I went to a friend’s house with the babies and I had forgotten to bring any formula or breastmilk. Suddenly the babies got hungry, and although my breasts had milk for them, none of us knew how to get it into their tummies. We tried to nurse, but they’d never learned to latch. They couldn’t extract what little milk I had to give them, and all they could do was scream.

Everything about nursing made me feel terrible, and there was nothing I knew how to do to solve our problems. The only thing that made me feel worse than failing at nursing was the thought of stopping. I spent far too much of those first months being miserable, and far too little time enjoying my babies.

My first turning point came when I read the last chapter of Healthy Sleep Habits, Happy Twins. You may recall that I was in the middle of reading this book when I went into preterm labor at 28w, but I was so afraid of something bad happening and not ending up bringing home twins that I couldn’t bear to read it. It remained half-read until after they were born, then I only had time to read the specific section relevant to them. It wasn’t until they were 7 weeks old and I was hiding away in my bedroom to escape my visiting MIL that I noticed the last chapter about breastfeeding. This chapter, more than anything else I’ve seen, dealt with the emotions I’d been having. Unlike the Mothering Multiples book, which basically told me to suck it up, the chapter acknowledged how very hard it was to try to nurse twins, and that sometimes it just doesn’t work the way you’d hoped.

My next turning point came soon after, when longtime blog reader (and mom of triplets) Cat recommended The Breastfeeding Mother’s Guide to Making More Milk. I wish that I’d found it sooner — it changed my life! The associated website is also rather helpful. Suddenly, it all made sense.

Some of the factors the book lists as increasing risk of low milk supply:

• Multiples, just because there are more mouths to feed. Check.
• C-section, for several reasons including different hormonal and biological process than vaginal birth leading to the nursing process not beginning in the same way; likely delay between birth and first nursing; anesthesia side-effects which can inhibit the milk onset. Check.
• Blood loss during birth. The book says it’s not really a problem unless you lose more than 2 units. I lost more than 6 units of blood. Big check.
• Preemies, who aren’t allowed to nurse at the breast for days or weeks then aren’t as capable at nursing once they do start. Check.
• Babies who are sleepy. For over a month my babies would regularly fall asleep in the middle of feeds. Check
• Formula supplementation, which reduces the amount of milk that the baby will need from the breast which then reduces the body’s production. Supplementation was mandatory in my NICU once the babies were off IV nutrition. Check.
• Feeding on schedule instead of on demand. The NICU runs on a strict schedule, so check.
• Endocrine issues. My thyroid is typically on the very low side of normal, but I have no idea what my levels were like during pregnancy or postpartum. I also could have other endocrine problems that have never been diagnosed. Maybe check.
• Infertility. I repeat, INFERTILITY. Big fucking check.

The book talks about PCOS as one specific infertility-related cause of low supply. I don’t have PCOS, but many infertile women do, so it’s important to know in advance.

There are a few other causes of low supply that I don’t have, like inadequate breast tissue (ha ha), but I have oh, so many.

To address the common causes of infertility and low supply, the book recommends figuring out what caused your infertility as it may help you diagnose the root of the supply problem. This is the only time that I wasn’t totally happy with this book. I spent many years and tens of thousands of dollars trying to figure out why I was infertile, thank you very much. I remain “unexplained.” That ship has sailed.

All of this is not to say that every woman who deals with any of these risk factors will automatically have problems nursing. Most won’t, and very few have the degree of problems that I have had. Still, I think it’s good to keep the potential for problems in mind beforehand so that you can be aggressive in squashing problems at the first sight of them. Next week I’ll talk about the ways that I tried to address the problems, as well as the things I didn’t do that I wish I had.

Thoughtful Thursday: Offer

Today’s Thoughtful Thursday is about a dilemma that just came up in my life. It has to do with breastfeeding, but in my mind it raises larger questions.

First, a note: I’ve had some posts about breastfeeding in the works for months and months. At first, I couldn’t get very far through writing them without bursting into tears. More recently, as I’ve come to a place of increasing acceptance, it’s been been less emotional but remains a sore subject. I really will write those posts eventually, because I would like to pass along what I have learned, much of which is particularly relevant to those with a history of infertility. In the meantime, in a nutshell: major supply problems, babies never learned to nurse, been exclusively pumping almost their whole lives to give them what little I can, 6 1/2 months and counting. I’ve started tapering my medications to begin the process of stopping, a decision that I came to after much struggle.

Today I got an offer from an acquaintance with a baby a few months younger than Burrito and Tamale. She lives in my neighborhood, and I think we’re working on developing a friendship, but I’ve literally only seen her three times. I happened to mention my milk supply issues, and she happened to mention her current surplus of milk. She offered me her surplus breastmilk.

Given that I have been exclusively pumping for half a year to provide only 5%-10% of each baby’s intake, often at great personal cost in terms of emotional well-being and time, clearly I believe extremely strongly in the benefits of breastmilk. One of the hardest things I’ve ever had to deal with has been my inability to provide for them in this way, despite trying as hard as I’ve ever tried with anything.

Pro of accepting her offer:

• Babies will continue getting breastmilk after I’m done pumping. They will probably get much more breastmilk than I’ve ever been able to give them.
• Lets her avoid wasting what she’s not able to use.

Cons:

• Feeling of indebtedness.
• There are babies out there who need the milk more, though I’m not sure if her milk would actually reach them.
• Possible exacerbation of already-present feelings of inadequacy.

Take your pick of which Thoughtful Thursday question to answer.

How much generosity can you let yourself accept?

or

What should I do?

For once, my head and my heart aren’t agreeing, and I’m truly stumped.

Thoughtful Thursday: URL

This is one of those “blogging about blogging” Thoughtful Thursdays.

How did you choose the name of your blog? If you had it to do over again, would you choose the same name?

I wrote all about the Radiohead song from which I got the name of this blog in my second-ever post.

The song lists all of the goals to which we aspire, simultaneously shining a light on our unquestioning pursuit of these goals.

The first few lyrics:

fitter
happier
more productive
comfortable
not drinking too much
regular exercise at the gym (3 days a week)
getting on better with your associate employee contemporaries
at ease
eating well (no more microwave dinners and saturated fats)
a patient better driver
a safer car (baby smiling in back seat)

It’s about living a conventionally good life. To me, it’s about questioning whether you really want to live each component of that conventional life.

Being infertile brings the purposeful pursuit of parenthood into clearer focus, although it also brings a lot of other crap with it too.

In choosing the name of the blog, I wanted a name that highlighted the quest for my elusive goal. I also wanted a name that would still apply once that goal had been achieved — I didn’t want to have to change the name down the road.

The only problem that’s come up is that many people insert “the” in the middle, as in Baby Smiling In The Back Seat. People also sometimes make back seat into one word.

Nonetheless, I’m very satisfied with the name I chose. I think it’s distinctive, evocative, and now, accurate — times two!

How did you choose the name of your blog? If you had it to do over again, would you choose the same name?

Disbelief

Burrito and Tamale are six months old now, and still, almost every day, I can’t quite believe that they’re really mine.

Thoughtful Thursday: Relationships

This is the last Thoughtful Thursday ever.

Naaaah, April Fools!

Welcome to April’s Intelligentsia, the people who commented on every Thoughtful Thursday post for the month of March.

Perfect record of #15: Wiseguy from Woman Anyone?
#11: Ernessa from Fierce and Nerdy and 32 Candles
#11: Photogrl from Not the Path I Chose
#10: Jill from All Aboard the Pity Boat
#9: Lost In Translation from We Say IVF, They Say FIV
#6: Elana from Elana’s Musings
#6: Mel, a.k.a. Lollipop Goldstein, from Stirrup Queens
#5: A from Are You Kidding Me?
#4: Ana
#4: Stacie from Heeeeere Storkey, Storkey!
#2: Michele from My Life After Loss
#2: Rebecca from Northern Grin

We’ve talked about how many children, domains of life, and blogs you can handle. One more.

How many offline relationships can you maintain? How do you feel about the number of relationships you have?

There are several friendships that I consider real, true friendships, even though we aren’t in frequent contact. When we see each other in person, it’s like no time has passed, but we email or call every few weeks, every few months, or even less. If I needed something, there are about half a dozen people on whom I could call. The infrequency of our contact is usually based on their time constraints or correspondence patterns than mine. If they wanted more frequent contact, I could probably manage.

There’s only one friend that I communicate with several times a week.

There are several relatives with whom I communicate several times a week, but generally our conversations are quite superficial. Nowadays, they’re almost entirely about the babies.

Since I mostly work from home now, I don’t have work acquaintances that I see on a regular basis.

My husband is the only person I talk to every day. Well, I suppose I talk to the babies every day, but they don’t talk back yet.

I wouldn’t mind another friend or two who lives nearby, since everyone that I care about who doesn’t live in my house instead lives hundreds or thousands of miles away. I have plenty of relatives and enough true friends, but it would be nice to see them a little more often. Ultimately, though, if I have my husband and now my children, my social circle is complete.

How many offline relationships can you maintain? How do you feel about the number of relationships you have?