Introduction

If you’re looking for clear answers about how Empty sella syndrome (ESS) could affect fertility, you’re in the right place. Our health library is rich of material and will explain how ESS affects fertility in detail. You’ll leave this article confident in your knowledge and with a good view of what ESS means for reproductive health.

Overview

Empty Sella Syndrome (ESS), sometimes called arachnoidocele, is a rare condition that affects the pituitary gland. This tiny gland is about the size of a grape, very small, right? It sits at the base of the brain and controls many body functions by sending hormones into the blood. ESS happens when the small space in the skull that normally holds the pituitary gland looks “empty” on a scan. However, it isn’t really empty because instead it gets filled with the fluid that cushions the brain and the pituitary gland is squashed flat against the wall. Therefore, the gland can be harder to see on the scans and sometimes it doesn’t work as it’s meant to.¹ ESS can be:

• Primary where the condition happens on its own²
• Secondary, which means it happens after surgery, radiation or other injury to the pituitary gland²

The pituitary gland may not produce enough of the hormones e.g., Luteinising Hormone (LH) and follicle-stimulating hormone (FSH). These are needed to trigger ovulation in women or support sperm production in men. The reproductive system can't work right without enough of these hormones, which makes it hard to conceive.³

Understanding ESS

So let’s start from the basics to give you some understanding about the syndrome. There are 2 types of ESS, which are called quite simply: primary and secondary.

• In primary ESS, the small space that holds the pituitary (sella turcica) looks empty in X-ray scans. It appears to come up more in women with high blood pressure and obesity. This type of ESS is believed to stem from minor anatomical issues in the sella turcica, which leads to a buildup of cerebrospinal fluid² 
• Secondary ESS occurs when the pituitary gland shrinks. This one could appear due to genetic mutations, injuries, radiation treatments or surgeries that result in the pituitary gland reducing in size²

Both primary and secondary ESS usually cause symptoms that are not life-threatening, although how strongly they appear can differ from person to person. The most common symptoms are headaches, lower sex drive and problems with erections. In some cases of secondary ESS, people may also notice their periods stopping, feeling very tired, changes in mood, problems handling stress or infection and sometimes infertility. If hormone levels are affected, doctors may suggest hormone replacement treatment along with regular check-ups. And finally, fertility issues can happen when ESS interferes with the pituitary hormones that control ovulation in women and sperm production in men.²

Pituitary gland and fertility

The pituitary gland is often called the “master gland” because it sends out chemical messengers (hormones) to other glands, telling them what to do. These hormones help with many things that keep you healthy. The front part of the pituitary makes several key hormones, such as growth hormone (GH, helps your body grow), prolactin (helps with milk production), adrenocorticotropic hormone (ACTH, tells your adrenal glands to make stress hormones), follicle-stimulating hormone (FSH, controls fertility and reproduction), luteinising hormone (LH, controls fertility and reproduction), and thyroid-stimulating hormone (TSH, controls your thyroid). The back of the pituitary gland makes two other hormones: vasopressin, which helps your body keep the right amount of water, and oxytocin, which helps with labour and bonding.⁴

In women, FSH helps eggs develop while LH triggers ovulation and supports the release of oestrogen and progesterone. In men, FSH supports sperm production and LH signals the testes to make testosterone. Fertility problems can occur when these hormones are low due to pituitary dysfunction.⁴ Prolactin (also a pituitary hormone) may also become abnormal in ESS. Excess prolactin can disrupt ovulation and menstrual cycles in women and reduce testosterone and sperm quality in men. Beyond this, other pituitary hormones indirectly affect reproduction. Remember TSH? After being produced by the front pituitary, it becomes important for thyroid hormone production by the thyroid gland.⁵ Thyroid imbalances can cause irregular cycles or reduced fertility. Therefore, the hormones that don’t affect fertility directly can still cause an unfavourable impact on it. Another example is how ACTH regulates the adrenal glands and low cortisol levels from adrenal dysfunction can lead to fatigue and poor stress tolerance. This can also make it harder for your body to maintain normal reproductive function.⁴

ESS and ovulation

Here we’re going to break down to you the grounds of conception. Everything starts with ovulation. Ovulation is when an egg is released from the ovary, usually about halfway through the menstrual cycle. This happens after a rise in two key hormones, FSH and LH, which work together to trigger the egg’s release. Oestrogen helps the egg and the womb lining prepare for ovulation and it rises just before the egg is released. After ovulation, progesterone takes over, making the womb ready for a possible pregnancy and helping to support it if fertilisation happens.⁶ As we’ve described to you, in ESS, the pituitary gland may not release enough of the hormones FSH and LH. This is a problem known as central hypogonadism. In women before menopause, this also lowers oestrogen levels and can lead to irregular or missed periods. Since FSH and LH are the signals that trigger the ovary to release an egg, their shortage can cause irregular ovulation or even stop ovulation completely. This is what causes infertility.^6,7

Fertility in women with ESS

Women who are affected by ESS might face fertility issues due to how the condition impacts hormone levels from the pituitary gland. In many premenopausal women, ESS is linked to central hypogonadism. So this is when levels of FSH, LH and oestrogen are lower than usual. This is then a lack of balance, which can lead to changes in periods, such as irregular cycles or even a total lack of periods. Since FSH and LH are the hormones that usually start ovulation, their low levels mean the ovaries might not release an egg as expected. This mess-up can cause irregular ovulation or no ovulation at all, which increases the risk of being less fertile or not being able to have children.^6,7

Control of ESS often varies depending on the seriousness of the hormonal imbalance. Hormone replacement therapy can be recommended if a certain hormone isn’t produced enough. This approach can help restore hormone levels and improve the symptoms linked to low pituitary output. Overall fertility care may include hormonal support as well as assisted reproductive technologies (ART). Treatments such as in vitro fertilisation (IVF) are commonly used when natural conception is difficult, and worldwide, millions of children have been born, thanks to IVF and similar methods.^7,8

Fertility in men

In men, ESS is connected to gonadotropin dysfunction. This complicated word means the pituitary gland does not make enough LH and FSH. This lack of testosterone can produce central hypogonadism, which can lead to low testosterone levels.⁷ When guys don't have enough testosterone, they might see a drop in sexual desires, get weaker or no erections, or even face problems getting an erection. Low testosterone can also make you feel tired, mess with your mood, and change how your body is made up, like more fat and less muscle. This issue, known as central hypogonadism, comes right from bad signals from the pituitary gland.⁹ Management of these can include hormonal therapies targeting restoring balance. In cases where bringing back hormone levels does not fully resolve fertility issues, assisted reproductive technologies (ART) may be considered. These can include methods such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI), which offer couples a pathway to conception when natural pregnancy is not possible.¹⁰

FAQs

Is there some kind of regular testing for ESS?

People commonly find out they have empty sella syndrome by accident, such as when they have brain imaging done for something else.¹¹

What are the two categories of ESS?

ESS can be divided into partial and total. In partial ESS, the cavity where the pituitary gland sits is taken up by spinal fluid, and the pituitary gland usually measures between 3 and 7 mm in thickness. In total ESS, more than half of the space is filled with fluid, and the pituitary is very thin (measuring 2 mm or less).¹²

Is there anywhere I can read a case report about fertility treatment in someone with Empty Sella Syndrome (ESS)?

Yes. A case report describes a 28-year-old woman with primary partial ESS who conceived healthy twins after IVF with ICSI, showing that assisted reproductive technologies can help women with ESS achieve pregnancy.³

Summary

Empty Sella Syndrome (ESS) is a rare condition where the “master gland” called the pituitary (that controls many hormones) becomes flattened by fluid. This can affect fertility because the gland may not release enough of two key hormones, FSH and LH, which are needed for ovulation in women and sperm production in men. Women may have irregular or missed periods, men can develop low testosterone, reduced sex drive or erectile problems. Treatment will depend on hormone levels and could include hormone replacement or assisted reproductive technologies like IVF or ICSI, which give couples a chance to conceive.