A. Renal Failure
Uremia is associated with infertility, decreased libido, erectile dysfunction, and gynecomastia. The cause of hypogonadism is controversial and probably multifactorial. Testosterone levels are decreased, and FSH and LH levels can be elevated. Serum prolactin levels are elevated in 25% of patients. It is likely that estrogen excess plays a role in hormone axis derangement. Medications and uremic neuropathy may play a role in uremic-related impotence and changes in libido. After successful renal transplantation, the hypogonadism usually improves.

B. Liver Cirrhosis
Hypogonadism related to liver failure may have various contributing factors. The reason for organ failure is important. Hepatitis is associated with viremia, and fevers can affect spermatogenesis. Excessive alcohol intake inhibits testicular testosterone synthesis, independent of its liver effects. Liver failure and cirrhosis are associated with testicular atrophy, impotence, and gynecomastia. Levels of testosterone and its metabolic clearance are decreased; estrogen levels are increased owing to augmented conversion of androgens to estrogens by aromatases. Decreased testosterone levels are not accompanied by proportionate elevations in LH and FSH levels, suggesting that a central inhibition of the HPG axis may accompany liver failure.

C. Sickle Cell Disease
As mentioned earlier, sickle cell disease can cause pituitary dysfunction, likely due to the sludging of erythrocytes and associated microinfarcts. This same mechanism may also occur in testis tissue and contribute to primary hypogonadism. As a result, spermatogenesis is decreased, accompanied by lower serum testosterone levels.