FMT implant advice/conundrum (clinic vs DIY)

[FallThrough22]

Hi guys
Simply in 2-3 months I am undergoing FMT therapy, namely for SIBO/SI dysbiosis, and I am curious on the best course of action between two options:
FMT implants at a clinic - using their donors (2-3) over several weeks (implant in the jejenum, via gastroscopy)
OR
FMT Oral Capsules + enemas (from a suppliers donors, 1-2) also over several weeks

Note: Total engraftment of the FMT's from the chosen donor(s) is likely to be increased following some therapies done prior to implant, and I am also travelling abroad - so I am trying to make the right decision.

My main struggle/concern in making this decision is regarding
1.) Donor quality, comparatively
2.) If perhaps implant via gastroscopy in the jejenum has any overt improvements over oral capsules; in outcomes or engraftment for example.

Method: Capsules vs jejenum implant:
I am limited to single encapsulated 000's; this is just how they come. I am aware of the Wiki and that double encapsulated would be best, but again this is just how they come.
On paper I can imagine the capsules would break down early in the stomach and certainly reach the duodenum - but I am unsure on total FMT load reaching the jejenum. Perhaps a lot of bacteria may be distributed in the duodenum and be killed off by bile acids or stomach acid (albeit a non issue with bicarb soda/alkaline water).
In which case, an implant into the first loop of the jejenum may be superior..

Donor quality comparsion

Gastroenterology clinic donors:
*I did not ask for extensive donor criteria and I am not sure I should, as it may be rude and they may not share that information.

I did however express my concern with donor quality, and what they did tell me was:
-The donors are young medical students
-Tested for all infection types over multiple stool tests (inferring here qPCR pathogens)
-Are not allowed if any GI symptoms or GI disease in the family
-Donors must not have a GI infection
-Donors must have had no antibiotics in the last year and not more than once in the past 5 years
-Donors are tested for microbiome quality via 16s stool test

Overall the gastroenterology clinic is quite functional - they prompted the idea of FMT therapy for SIBO in the first place, and they offer therapies which are more niche and cutting edge. I am inferring they also use the same standard criteria as other clinics, in addition to what they shared

*The clinic did not mention how recently their donors were tested, but of course they could be using stool that has long been banked

DIY/FMT supplier donors:
*Donors appear to be extensively tested; having chatted with the organiser, they (like Michael) spent a great deal of time with stringent criteria in choosing, and have been supplying FMT's for multiple years
-Essentially a mix of European consensus criteria // the Human microbes criteria
-Donor information is available: are in their teens, eat homegrown fruit/veg, are active. Likewise to clinic criteria their family have no gut issues. Interviewed in person and appear outwardly well and happy.
-Donors are screened for mental health and family's mental health
-Donors are tested for the qPCR pathogens every month, results are available to me
-Donors have 16s test results for microbiome quality, also available to me - one test done in April 2024, and again soon in December 2024. The results appear very good.

Note: I'm aware of the limitations of 16s testing both in regards to its detection and stool tests in general often being hard to replicate. One could infer multiple stool tests in this case may be a suitable option given this - where it allows you to find the overall "trend" or "mean" result. The same can be true for any set of data, I feel. So although 16s is limited in scope - with two tests done recently I think this is at the least partly valuable. The clinic also uses 16s testing, which is notable.
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Overall it seems the clinic donors and FMT supplier donors are tested much the same; standard screening pathogens, background assessed and 16s assessed.
With that said, I have more information available to me on the donor quality from the FMT supplier, and they would appear to be more frequently tested. If I am also to infer things, it seems the DIY donors may be more thoroughly tested. If I am to go with my gut it seems like this may be the better option, but again a jejenum implant may well be vastly superior - hence my query.

Has anyone done a jejenum FMT implant vs DIY? Was there any overt additional benefit?

 

[FallThrough22]

Hypothetically the most "ideal" option could be to see if the clinic would allow for patient donor selection - but I did ask this and was not given a direct yes/no answer; I am assuming the latter

 

[Michael Harrop]

SIBO

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Did you review the wiki? This is not a real condition.

I would never use an unknown, unverifiable donor whose results are not being publicly and systematically tracked and reported.

But your alternative is an unknown "a suppliers donors", which may not be any better.

In my experiences with 15+ different donors, nothing comes close to being as important as donor quality. So nothing else you mentioned would be a consideration for me.

I am not sure I should, as it may be rude and they may not share that information

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Lmao. This is like reading an article that at least 1/3rd of medical interventions are not evidence-based and then thinking it would be rude to ask your doctor if the procedure they're recommending is evidence-based.

That's a mild way of putting it. FMT from a bad donor can make you worse, give you new problems, and even be life-threatening. So if you rate "worried about being rude" over "being alive and not suffering unnecessarily" then sure, don't ask them.

they (like Michael) spent a great deal of time with stringent criteria in choosing, and have been supplying FMT's for multiple years

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There is no supplier I know of that comes close to having as stringent criteria as Human Microbes. There's something erroneous about the way you're rating and comparing suppliers.

Nowhere did you or they mention stool characteristics, which seems to be the most important factor, by far.

more frequently tested

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Largely irrelevant.

 

[FallThrough22]

Thanks Michael

Have you seen any literature comparing jejenum implant vs other methods?
As I mentioned the supplier in question has published tests for their donors and recipient results are also publicly available, rest assured. The stool characteristics I will look into, this is a good point. Albeit I have chatted with a couple of sick people with gut problems and they claim their stool consistency is great

SIBO/small intestine dysbiosis - call it what you will - is a very real condition. At least the gastroenterology clinic seems to think so, as well as Dr Jason Hawrelak and many other gastroenterologists the world over. I won't argue semantics though, that's not what this post is about.

I disagree on the characteristics of stool only being the most important factor - I would very much prefer the donor I am receiving to have been 1.) recently tested (preferably multiple times given the climate on stool test reliability/reproducibility) 2.) and not have high levels of problematic bacteria (which are consistently turning up in my own stool results, also proving to be problematic).

 

[Michael Harrop]

As I mentioned the supplier in question has published tests for their donors and recipient results are also publicly available, rest assured

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As I mentioned, this is largely irrelevant.

they claim their stool consistency is great

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Tons of donor applicants with terrible stool quality confidently tell me theirs is perfect.

SIBO/small intestine dysbiosis - call it what you will

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No, you should not "call it what you will". There's a huge difference and SIBO is not real. It's not semantics; so saying it is tells me you didn't adequately review that wiki page. That kind of wilfully ignorant attitude is anathema here. Please review the rules.

I disagree on the characteristics of stool only being the most important factor - I would very much prefer

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It's irrelevant what you prefer. I would prefer that the temperature weren't close to freezing where I am. That doesn't change reality. You disagree because you're not well-informed on the subject.

For your #2 preference, it's covered here: https://forum.humanmicrobiome.info/threads/fmt-donor-matching-and-selection-screening-for-specific-microbes-and-p.148/

 

[joe]

What is the name of the clinic?

 

[SFBayFMT5]

I'm guessing you're not in the United States, judging based on the clinics and suppliers that are available to you. Human Microbes was the only US supplier for DIY FMT, and they are no longer shipping, which means now there are zero based here--and no clinics offer endoscopic FMT treatment for SIBO. The best foreign supplier I have found also recently shopped shipping to the United States. Being elsewhere in the world alters your options significantly.

In my case, the dose-limiting issue with ALL capsules has been nausea/upset stomach, which has occurred around the same dosage level (3-4 capsules) for all donors and preparation methods, regardless of how much or little those capsules helped the conditions I'm actually trying to treat (IBS and neuropsychiatric symptoms). This was completely not an issue with my first FMT nine years ago, which was via gastroscopy into the jejunum. That FMT also improved my health WAY more immediately than any of these capsules.

This agrees with what Dr. Magdy El-Salhy in Norway has found for IBS--if you read his studies, jejunal FMT is very significantly better than placebo (P < 0.0001 I believe, if you don't now what that means it's a measure of how likely the difference is due to chance), colonoscopic FMT is barely but still significantly better than placebo, and capsules are actually WORSE, i.e. the placebo is on average better.

I've recently tried FMT by enema--as expected I could tolerate a significantly larger dose because it could bypass the stomach (the donor was the same as one I had previously used for capsules). This has made it more efficacious, but it's still not up to the level of the gastroscopic FMT--so if you can get that, I STRONGLY urge you to do it. It seems that route is significantly less affected by the donor than other routes--I did no donor matching at all for that FMT, and it was my first one, yet it worked like a charm with no side effects. Or maybe I just lucked out.

If you don't want to go with that clinic, do try enema, not just capsules (combining them won't HURT, but if you must do one OR the other, I would choose the enema). It does seem to work better for people with a history of IBS (I won't say "SIBO", as I do think that's rather a misnomer due to the fact that these bacteria only grow because the bacteria you really need are gone). I have seen multiple people say that and there's definitely some truth to it.

 

[Michael Harrop]

gastroscopic FMT--so if you can get that, I STRONGLY urge you to do it. It seems that route is significantly less affected by the donor than other routes

enema). It does seem to work better for people with a history of IBS

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This has not been my experience. I have IBS and my first donor was highly effective and I did deep retention enema only. More recently, I stopped doing lower-route because it didn't seem to have any benefits, only detriments. However, there was at least one donor where lower-route seemed to give additional benefits to upper.

 

[SFBayFMT5]

This has not been my experience. I have IBS and my first donor was highly effective and I did deep retention enema only. More recently, I stopped doing lower-route because it didn't seem to have any benefits, only detriments. However, there was at least one donor where lower-route seemed to give additional benefits to upper.

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It seems your experience fits exactly what I was saying--your most effective experience so far has been with deep retention enema. Most donors you have done only capsules with have been of limited effectiveness. To my knowledge you have never had a FMT via gastroscopy, so you cannot comment on that from personal experience. I have--I've done endoscopy, capsules, and retention enema. I haven't had the chance to test multiple donors with each, but the endoscopy seems to be the clear winner, which agrees with the formal studies done in Norway.

I'm not saying that capsules can never work, or that combining capsules with another route is a bad idea--all I'm saying is that it seems much harder to get the capsule route to work correctly, when used alone, than the others. As in, across the population of all healthy donors, possibly 1 in 10 will be successful for a particular IBS patient with capsules only, but 50% of healthy donors will work for that same patient when given via endoscopy (those are just made-up figures, but you get the point).

 

[Michael Harrop]

your most effective experience so far has been with deep retention enema

Most donors you have done only capsules with have been of limited effectiveness

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No, that's not correct. It seems you either haven't read my experiences yet, or forgot. One of the most effective donors was upper-route only, no capsules. Another, I tested lower vs upper and lower was incomplete without upper.

Again, it's important that you read existing information before commenting and coming to erroneous conclusions, and thus spreading bad info.

it seems much harder to get the capsule route to work correctly, when used alone

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I don't think so. I don't see that supported in the literature either, which you can review in the wiki.

those are just made-up figures

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Yes, completely made up and erroneous (see citations).

You seem highly inclined to be poorly informed, come to errroneous conclusions, and spread bad information/misinformation. Please reflect on this and make changes.