Deciphering Sperm Telomeric Functional Homeostasis in Male (In)Fertility: An Integrative Molecular Diagnostic Stratification Approach Toward Precision Diagnostics

Purpose Telomeres is essential in maintaining genome integrity. Alteration in telomere homeostasis in sperm cells is associated with male infertility by means of various mechanisms. Here, we aim to design and evaluate comprehensive multidimensional metrics associated with sperm telomere homeostasis as advanced epigenetic molecular prognosticators, which provides a significantly improved diagnostic framework for accurate predication of Male (in)fertility. Methods Relative telomere length, mRNA expression of human telomerase reverse transcriptase (hTERT) and shelterin complex (RAP1, POT1, TPP1, TRF1, TRF2), was determined using log ₂ fold change. Multivariate frameworks were developed based on Composite Telomere Indices Outcome. Receiver Operating Characteristic Curve assessment was performed to assess diagnostic efficacy. The clinical net benefit of utilizing comprehensive matrices was assessed by performing Calibration Curves, Confusion Matrices, and Decision Curve Analysis. Results Sperm telomere length was significantly reduced in all infertile subgroups over controls ( p  < 0.001), with large nonparametric effect sizes. hTERT and Shelterin complex RAP1, POT1 and TPP1 demonstrated significant downregulation ( p  < 0.01), whereas TRF1 and TRF2 were significantly upregulated ( p  < 0.01). Multivariable models demonstrated higher discrimination than the THC model (maximum ΔAUC ≈ 0.49; p  < 0.0001), alongside improved calibration and decision curve-based net benefit. Conclusion The combined impact of epigenetic influenced on telomeric matrices enhances the risk stratification of male infertility beyond sperm telomere length alone. This approach establishes telomere integrity matrix that provides a quantifiable molecular framework for potential telomere-centric diagnostics in andrology, which may assist in personalized therapeutic strategies for precise prediction of male infertility causative factor.