The impact of paternal obesity and metabolic disease on semen quality and fertility outcomes is not fully appreciated. With obesity rates on the rise, researchers have studied the intricate relationship between paternal body mass index, metabolic health, and male fertility. This systematic review identified 112 articles in the Medline Database between 2013 and 2023 that investigated the effects of body mass index, diabetes, metabolic syndrome, exercise, weight loss medication, or bariatric surgery on semen parameters, sperm quality, or fertility outcomes. This review suggests that obesity, diabetes and metabolic syndrome have a negative impact on various parameters of male fertility, from semen quality to sperm DNA integrity. There is also mounting evidence that male obesity negatively correlates to live births via both natural conception and assisted reproductive technologies. Lifestyle interventions such as physical exercise generally appear to improve male fertility markers; however, the type and intensity of exercise may play a crucial role. Pharmacological treatments for weight loss, such as metformin and GLP-1 agonists, present a more complex picture, with studies suggesting both beneficial and detrimental effects on male reproductive health. Similarly, surgical interventions like gastric bypass surgery show promise in improving hormonal imbalances, but have mixed effects on semen parameters. Future research is needed to clarify these associations and inform clinical guidelines. In the interim, health practitioners should incorporate these insights into clinical practices, encouraging proactive lifestyle changes and providing targeted treatments to improve male reproductive health.Copyright © 2023. Published by Elsevier Inc.