<p>Mesenchymal stem cells (MSCs) are highly valuable for their potential in cell therapy and tissue engineering because of their self-renewal, multilineage differentiation, and immunomodulatory capabilities. Adipose-derived mesenchymal stem cells (AD-MSCs) are advantageous in regenerative medicine because of their accessibility and ease of isolation. However, the clinical application of MSCs faces challenges related to large-scale culture (LSC) expansion, which is required to generate enough cells for transplantation but also decreases their therapeutic properties. This review assesses the impact of LSC on MSC functionality, differentiation potential, and immunomodulatory properties, and identifies key factors, such as metabolic shifts, genetic instability, and altered secretory profiles, that can compromise their therapeutic potential. We explored how prolonged in vitro passaging decreases MSC functionality and increases the risk of genetic alterations. In addition, strategies to preserve the efficacy of MSCs during scaling are discussed. A comprehensive literature review was conducted using PubMed, focusing on in vitro and in vivo studies that evaluated the effects of LSC on MSCs. These findings provide insights into optimizing culture protocols to maintain the clinical efficacy of AD-MSCs in regenerative therapies, addressing the critical need to balance large-scale expansion and functional integrity.</p> Graphical Abstract <p></p>