The Missing Half of the Preconception Conversation

"When couples come to us struggling to conceive, there is a pattern I have seen play out time and time again". Dr Nicole McPherson, Director of Research, Education and Diagnostic Laboratories at Genea talks about the latest research.

The woman has already had blood tests, hormone panels, and ultrasounds. She has been taking folate for months, watching her diet, cutting back on alcohol. Her partner has often had some basic assessment too, but far less, and usually later. A semen analysis requested weeks after the female workup is already well underway. Sometimes after months of investigation focused almost entirely on her.

This is not a criticism of GPs or couples. It reflects something deeper: a healthcare system, and a culture, that has long treated pregnancy and its outcomes as primarily a woman’s responsibility. A landmark review published in The Lancet this month is asking medicine to recognise that imbalance, and as a researcher/scientist who has spent my career studying male reproductive health and fertility, I think the moment we have been waiting for may finally be here.

Fertility has always taken two. Preconception health should too.

Most people understand that a man contributes half the genetic material to a pregnancy. What is far less appreciated is how much his broader health, wellbeing, and life experiences before conception shape what happens next.

This goes well beyond sperm count. The research now shows that a father’s weight, diet, mental health, alcohol use, and stress levels in the months and years before conception leave marks on the sperm that can influence embryo development, pregnancy complications, and the long-term health of the child, including their metabolic health, neurodevelopment, and mental wellbeing. In one large study of over half a million Chinese couples, fathers who reported any preconception alcohol consumption had a 35% higher rate of birth defects in their infants compared with non-drinking fathers. Paternal age, paternal depression, and paternal smoking all carry their own documented risks.

The Lancet paper goes even further, arguing that it is not just what a man does in the months before conception that matters. It is the arc of his whole life. Early childhood experiences, including poverty, trauma, and neglect, shape a man’s stress response, his mental health, his ability to be a supportive partner, and even the biology of his sperm. A 20-year longitudinal study found that men who experienced subclinical depression or anxiety as teenagers were almost five times more likely to experience significant psychological distress during their partner’s pregnancy compared with men without that history.

This is not about blame. It is about opportunity.

Semen analysis as a window to men’s health

In my own research, my team and I have argued that spermatogenesis is exquisitely sensitive to environmental and lifestyle factors, and that disruptions in sperm production can signal underlying systemic issues that predict long-term health risks, including cardiovascular disease and metabolic disorders. Men with abnormal semen parameters carry increased risks of chronic disease, certain cancers, and premature mortality. A semen analysis is not just a fertility test. It is a window into a man’s overall health.

What makes this particularly important is the opportunity it creates. Many men who would otherwise never engage with the healthcare system are motivated to do so when they are trying to start a family. Fertility is closely tied to a man’s sense of identity and his aspirations for fatherhood. That motivation is a powerful lever for change. A conversation that begins with sperm health can open the door to discussing weight, nutrition, alcohol, mental wellbeing, and the kind of broader health assessment men in their reproductive years so rarely receive.

Why have we ignored men for so long?

The honest answer is that medicine has, for a long time, treated pregnancy and its outcomes as primarily a woman’s domain. Women have borne not only the physical demands of pregnancy but also the cultural expectation that reproductive health is their responsibility to manage. Research funding, clinical guidelines, and public health messaging have followed that assumption.

The result is striking. Half of international clinical preconception guidelines contain no recommendations whatsoever for male preconception health. A United States study found that two thirds of men had unmet preconception healthcare needs. And when men are excluded from the conversation, we lose the chance to identify risks, address modifiable factors, and support healthier pregnancies and children.

One in six Australian couples experience infertility, and male factors are involved in approximately 50% of cases. Yet the investigation still tends to start with the female partner and work backwards. By the time male factor is identified, the couple has often already lost months of precious time.

What this means in practice

If you and your partner are thinking about starting a family or are already trying to conceive, here is what the evidence now supports.

Men should be assessed at the same time as their partners, not as an afterthought. A semen analysis is a starting point, but it is not the whole picture. A man’s general health, lifestyle, mental wellbeing, and any chronic conditions are all relevant to reproductive outcomes.

Modifiable factors matter and there is a real window of opportunity. Sperm take approximately 70 to 90 days to develop, which means that lifestyle changes made three months before trying to conceive can meaningfully affect sperm quality. Weight, nutrition, alcohol intake, sleep, stress, and smoking are all factors a man can act on.

Mental health is not separate from reproductive health. The research is clear that paternal depression and anxiety affect not only a man’s capacity to be a supportive partner during pregnancy, but also child developmental outcomes. If a man is struggling, addressing that is genuinely part of preconception care.

Support matters beyond the clinic. The Lancet paper draws attention to the ways in which financial stress, cultural norms, and systemic barriers create real challenges for men engaging with their own reproductive health. Acknowledging those barriers is the first step to helping men overcome them.

What we offer at Fertility SA

At Fertility SA powered by Genea, male factor infertility is not an afterthought. We assess both partners from the outset, and we have the specialist expertise to go well beyond a standard semen analysis when the clinical picture warrants it.

Dr Bruno Radesic, Medical Director of Fertility SA, is the only specialist in South Australia who can perform microsurgical testicular sperm extraction, the gold-standard procedure for men with non-obstructive azoospermia. For men who have been told they have no options for biological fatherhood, this procedure can change that conversation entirely.

We also know that a diagnosis of male factor infertility carries significant emotional weight. Our team includes fertility counsellors who work alongside our clinical and scientific staff to ensure men are not navigating this experience without support.

A new conversation

I have spent much of my career researching how a father’s health influences not just fertility, but embryo quality, pregnancy outcomes, and the long-term health of children. The science in this space has been building for years. What this Lancet paper does is draw it together in a way that is difficult to ignore.

The most important shift it asks for is not a clinical one. It is a cultural one. We need to stop treating preconception health as something women do alone, and start treating it as something couples do together. That means testing both partners earlier, having broader conversations about men’s health at the point of preconception, and building a system that genuinely includes men rather than one that reaches for them only after the female workup is exhausted.

If you are planning a pregnancy and would like to talk through what preconception care looks like for both of you, our team at Fertility SA is here to help. Because the healthiest pregnancies and children begin with two people who are both informed, supported, and cared for.