Bring a large pot of salted water to a rolling boil. Add the fettuccine and cook until al dente, about 8-10 minutes. Reserve ½ cup of pasta water, drain, and set aside.

In a large skillet, melt 2 tablespoons of butter over medium heat. Add minced garlic and sauté for 1-2 minutes until fragrant.

Stir in pumpkin puree and heavy cream. Heat through for 3-5 minutes until bubbling.

Gradually whisk in Parmesan cheese until melted and creamy. Adjust consistency with reserved pasta water if needed.

Add drained fettuccine to the skillet and toss to coat in the sauce. Season with salt and pepper.

Serve on plates or bowls, garnished with parsley or sage and toasted pumpkin seeds if desired.