Male infertility: is prevention the missing piece?

Introduction Male infertility affects nearly half of infertile couples and is increasingly recognized as a marker of overall male health rather than a condition limited to reproductive function. Despite growing evidence supporting early andrological assessment, preventive male reproductive healthcare remains underutilized. This study evaluated the reasons for accessing semen analysis, the prevalence of seminal abnormalities at first evaluation, and the clinical factors associated with impaired semen quality in a contemporary Italian cohort. Methods We conducted a single-center cross-sectional observational study including 930 consecutive men undergoing semen analysis at a tertiary fertility center between November 2023 and January 2024. Participants completed a structured questionnaire collecting demographic, clinical, reproductive, and lifestyle information. Semen analyses were performed according to the WHO 2021 Laboratory Manual. Patients were initially classified according to the indication for semen analysis (preventive screening, clinical follow-up, or fertility assessment), and subsequently according to previous semen analysis and previous andrological evaluation. Multivariable logistic regression was used to identify independent predictors of WHO-defined seminal abnormalities. Results The median age was 37.5 years (IQR 33.8–41.4). Fertility assessment represented the primary indication for semen analysis (88.7%), whereas only 3.4% of men underwent testing for preventive purposes. Overall, 32.2% of participants were undergoing their first semen analysis, and among these, 76.3% had never received an andrological evaluation. Men typically accessed reproductive health services only in their late thirties. At first semen analysis, abnormalities were frequently detected, including impaired total progressive motility (61%), abnormal morphology (70%), reduced sperm concentration (25%), and reduced total motility (32%). Multivariable analysis identified varicocele as the strongest and most consistent independent predictor of seminal abnormalities across multiple parameters, whereas age and body mass index showed selective associations. Smoking and alcohol consumption were not independently associated with semen impairment. Discussion Preventive andrological care remains markedly underutilized, with most men seeking evaluation only after fertility becomes a concern. The high prevalence of seminal abnormalities at first assessment highlights a missed opportunity for earlier diagnosis and intervention. These findings highlight the underutilization of preventive andrological care during adolescence and early adulthood, emphasizing the importance of awareness of male reproductive health and timely clinical evaluation.