Supporting fertility at advanced maternal age: A functional medicine approach with Dr. Cindy Geyer

People are waiting longer to have children for many reasons, ranging from expanded education opportunities to later formation of committed partnerships. They may also feel a greater responsibility and desire to be able to support children both financially and emotionally.  At the same time, women are concerned about their ability to successfully conceive if they wait too long. Fortunately, functional and lifestyle medicine approaches can not only help optimize fertility but also support a healthy pregnancy.

In our functional medicine clinic, we commonly see a combination of hormonal shifts, metabolic changes, nutrient depletion, and stress load shaping fertility in the late 30s and 40s. The goal isn’t to create fear around age, it’s to optimize the body’s internal environment so fertility is supported as comprehensively as possible.

RELATED: The ultimate preconception guide: What to do when you’re ready to get pregnant

What is considered advanced maternal age (AMA)?

The term “advanced maternal age” (AMA) refers to pregnancy at 35 years or older and is used to help increase awareness of the higher statistical risk for genetic issues, miscarriage, gestational diabetes, hypertensive disorders of pregnancy, preterm birth and C section rates. The increased risk is likely related to declines in egg quality and increased prevalence of underlying health conditions in the mother. 

However, it is important to recognize that many women over 35 have healthy pregnancies and healthy babies: chronologic age is not the same as biologic age! Common imbalances we assess and address in functional medicine such as inflammation, insulin resistance, nutrient deficiencies, hormonal shifts, stress and insufficient sleep influence egg quality and maternal health. By taking a personalized approach to identifying and addressing these root causes, we can support a woman’s fertility journey.

How fertility changes with age and what functional medicine looks at differently

Most women are aware that they have the highest number of eggs at birth, and that egg quantity decreases steadily with age. However, egg quality may be a bigger contributor to fertility between 35 and 45. Egg quality is not just about the egg, it’s also about the environment in which it develops. 

Research shows that as ovarian function declines, the surrounding tissue shows more fibrosis (scarring/loss of flexibility); endothelial (blood vessel) function declines; and there is increased stress-related nerve activity. These changes reduce egg nourishment and health. 

What are the drivers of changes in egg quality and the surrounding ovarian environment?

Mitochondrial dysfunction and ovarian aging

The ovaries are rich in mitochondria, the “energy powerhouse of the cell” which are also proverbial canaries in the coal mine. Mitochondrial dysfunction contributes to cellular aging and ovarian dysfunction. 

Factors that negatively impact mitochondrial function:

• Nutrient deficiencies: B vitamins, Coq10, magnesium

• Exposure to toxins such as BPA/microplastics/phthalates/ air pollution

• Oxidative stress: imbalance between free radical production and antioxidant neutralization. There are genetic susceptibilities to oxidative stress, but exposure to toxins along with diets high in excess calories, ultraprocessed foods, and not enough antioxidant and polyphenolic rich foods (think colorful vegetables and fruits!) are some of the biggest drivers of oxidative stress.

Fibrosis, inflammation, and the ovarian environment

This is seen with chronic immune stimulation/inflammation, which can occur with food allergies and sensitivities, gut microbial dysbiosis and/or increased intestinal permeability, and insulin and glucose dysregulation.

Endothelial function, healthy blood flow, and egg nourishment

The endothelium is the inner lining of blood vessels and can be negatively affected by ultraprocessed foods, nutrient deficiencies (magnesium, folate and omega 3’s), insulin dysregulation, toxic exposure, stress, high blood pressure and oxidative stress. 

Clinical clues that someone may need endothelial support include high blood pressure, including “white coat” elevations, Raynaud’s syndrome or migraine headaches. 

Stress, sympathetic activation, and hormonal signaling

Increased sympathetic innervation is driven by chronic stress that occurs with insufficient sleep, overexercising, nutrient depletion from malabsorption or calorie restriction, stressful work environments and relationships.

Stress also interferes with hormonal signaling and ovulation. Daily perceived stress can lead to lower estrogen, progesterone and higher FSH levels for women, which can in turn increase stress reactivity, creating a feedback loop. 

Common patterns seen in functional medicine practice for AMA fertility

In practice, many women navigating unexplained infertility over 35 or secondary infertility share a handful of common patterns. These are not meant to be labels but rather, they are areas functional medicine often assesses to support fertility at advanced maternal age.

Endometriosis and inflammation

This affects about 1 in 10 women worldwide and can cause scarring that affects fertility.  While many women with endometriosis have a history of heavy painful periods, others have few symptoms until they experience difficulty conceiving.

While endometriosis is best diagnosed and managed with an endometriosis specialist, the underlying principles of functional medicine complement specialty care by assessing and addressing contributors to inflammation, autoimmunity, gut dysbiosis and intestinal barrier integrity, as well as hormone processing which play a role with endometriosis.

RELATED: Endometriosis FAQ: Understanding symptoms, testing, fertility & advocacy with expert Dr. Benjamin Zaghi 

Subtle thyroid dysfunction and autoimmunity (including Hashimoto’s)

The standard reference ranges for “normal” thyroid may not be optimal for ovulation and fertility and can miss reduced cellular conversion of thyroid hormone to its more active form. Autoimmune inflammation of the thyroid gland (hashimoto’s) can also contribute to thyroid dysfunction and affect fertility.

RELATED: Hashimoto's wasn’t part of my pregnancy plan

Blood sugar dysregulation, insulin resistance, and ovulation

Blood sugar dysregulation and insulin resistance are common and are strongly influenced by diet and lifestyle. Insulin resistance is prevalent in women with polycystic ovarian syndrome and contributes to hormonal dysregulation and reduced ovulation. 

Gut dysbiosis, intestinal permeability, and hormone balance

Gut dysbiosis and increased intestinal permeability influence hormone balance and contribute to chronic inflammation, autoimmunity and insulin resistance. Celiac disease is a “do not miss” in any women struggling with fertility as you can have celiac disease as an adult in the absence of digestive symptoms

Stress, fertility, and the emotional load of trying to conceive

As noted above, stress is a significant contributor to ovarian aging, egg quality and hormone regulation. Chronic stress is associated with lower pregnancy rates with assisted reproductive strategies.  

Stress can include physical stress, such as overexercising or overly restrictive diet patterns, insufficient sleep and working long hours. Our perception of stress further increases its effects on our bodies. It is important to recognize the stress that can come from struggling to conceive and the emotional impact that may result. Having compassion for yourself, nourishing your body, taking time for restorative practices and rest, and talking to friends or finding support can help mitigate the impacts of stress. 

Insufficient sleep and circadian dysregulation

Insufficient sleep (quality, quantity, and timing) contributes to insulin resistance, hormone dysregulation and chronic inflammation. Sleep disordered breathing can present differently for women and is commonly overlooked, while restless leg syndrome and insomnia are more prevalent in women. 

Many of us are in a state of circadian dysregulation due to eating late, spending time on phones or screens before bed, having difficulty getting up in the morning and relying on caffeine to get through our days. 

How functional medicine can support fertility at advanced maternal age

Comprehensive lab testing beyond standard fertility panels

In functional medicine we start with a detailed history to gain insight into potential factors contributing to fertility and health, in addition to understanding your goals and concerns. Comprehensive testing beyond standard fertility panels can include: 

• Thyroid markers (TSH, free T3/T4, antibodies)

• Metabolic markers (fasting insulin, A1C)

• Inflammatory and oxidative stress markers

• Micronutrient status

• Hormone patterns across the cycle

• Salivary cortisol patterns throughout the day

• Mitochondrial metabolites

• Assessment of the gut microbiome and intestinal barrier health

• Screening sleep quality and quantity

Supporting egg quality and cellular health (mitochondria, antioxidants, sleep)

Start with a foundation of a whole foods nutrition plan emphasizing protein quality and quantity, anti-inflammatory and endothelial supporting fats from fish, nuts, seeds and EVOO, and an abundance of colorful veggies and fruits such as dark leafy greens, cruciferous veggies, and deeply pigmented berries.

• A 12 hour fasting window between dinner and breakfast may be beneficial without negatively impacting fertility (especially during the luteal phase).

• Longer fasting intervals (with guidance) may improve mitochondrial function and ovulation regularity in women with PCOS.

• Moderate exercise is one of the best-known lifestyle strategies to help regenerate mitochondria and improve function (in addition to its well-researched benefits on stress, mood, and insulin signaling).  However excessive exercise can increase free radical production/oxidative stress, further damaging mitochondria. Balancing movement and recovery time is key.

• Boosting antioxidant support by increasing intake of colorful fruits and vegetables, along with targeted supplemental support can improve cellular/ovarian aging and mitochondrial function.

Sleep not only impacts insulin signaling and inflammation, but newer research shows that sleep is important for mitochondrial regeneration and repair. Melatonin, which is involved in circadian rhythm regulation and starts to rise in the brain a few hours after dark, has powerful antioxidant and mitochondrial protective properties. Levels of glutathione, referred to as the “mother of all antioxidants”, recover during sleep. 

Strategies to optimize sleep start in the morning: seeing the sunlight, breaking your fast and moving your body sends signals throughout the body and brain that it is day. Aim to keep wake times and sleep times as consistent as possible. In the evening, carving out enough time to wind down and ease into rest; creating a sanctuary that is dark, quiet and cool; stopping screens at least 1-2 hours before bed; eating your last meal at least 3 hours before bed; and engaging in a relaxing practice such as gentle stretching or a warm bath can optimize the mitochondrial and metabolic benefits of sleep. 

Nervous system & stress regulation (ovulation, implantation, resilience)

Because stress can influence estrogen, progesterone, and FSH signaling, fertility support at advanced maternal age often includes a nervous system lens: reducing chronic sympathetic activation and building parasympathetic “rest and restore” capacity through sleep, recovery, boundaries, and restorative practices.

Nutrition as a foundation for fertility after 35

For supporting egg quality and an optimal ovarian environment, reducing oxidative stress and inflammation, improving insulin signaling and mitochondrial function and supporting healthy hormonal production and metabolism, nutrition becomes increasingly more important as we get older. 

Chronic stress, certain medications, gut imbalances and food processing can affect nutrient needs and availability, and many women enter their late 30’s with nutrient insufficiencies or deficiencies. The sooner the better to focus on healthy nutrition and micronutrient support for optimizing fertility and pregnancy outcomes. 

The 3-6 month window before pregnancy is especially critical: this is when the egg and sperm are maturing, nutrient stores are being drawn upon, and early placental development is being programmed.

A fertility-supportive diet focuses on adequate nourishment rather than restriction. Key components include the following:

• Adequate protein (including quality, quantity and timing of intake) to support hormone production, detoxification, immune function, egg and sperm development, uterine lining integrity, and early fetal tissue growth.

• Blood sugar balance: pairing protein and fat with fiber rich carbohydrates, avoiding long fasts, and minimizing simple sugars can help stabilize blood sugar and support ovulation, implantation and reduce pregnancy complications.

• Fats are essential for hormone production and absorption of fat-soluble vitamins (A, D, E, and K). Extra virgin olive oil, nuts, seeds, and avocado are great sources, while omega-3 fatty acids from fatty fish like wild salmon, sardines, and small mackerel reduce inflammation and improve egg quality.

• Micronutrients: 

• Folate (B9): Essential for DNA synthesis, cell division, and early neural development. Adequate folate status before conception is critical.

• Iron: Low iron stores are associated with anovulation and early pregnancy loss. Many menstruating women are unknowingly depleted.

• Vitamin D: Functions as a hormone, influencing ovulation, immune regulation, implantation, and pregnancy outcomes.

• Choline: Critical for egg quality, placental development, and fetal brain development, yet commonly under-consumed.

• Antioxidants: Help protect developing eggs from oxidative stress, which increases with age and inflammation.

Lifestyle shifts that can positively impact fertility at advanced maternal age

Additional lifestyle strategies that can positively impact fertility:

• Prioritize sleep quality, quantity and timing: sleep is a fertility hormone regulator, improves stress resilience and insulin signaling, supports mitochondrial function and reduces inflammation and oxidative stress. Talk to your provider if you are experiencing difficulty falling or staying asleep, have symptoms of restless leg syndrome or awaken unrefreshed. 

• Regular moderate exercise/movement: improves insulin sensitivity, endothelial function/ healthy blood flow, and mood/stress resilience. Listen to your body and honor the balance between exertion and recovery.

• Take common sense steps to reduce environmental toxin exposure: 

• Minimize intake of packaged and processed foods

• Use glass food storage containers

• Consider a water filter and air filter

• Choose fish low in mercury and safe for pregnancy

• Support a healthy circadian rhythm by maintaining a consistent sleep: wake cycle and timing your eating, movement and light exposure to align your brain, body, organ and cellular clocks.

RELATED: Boosting male fertility: Why sperm health matters more than you think 

A reframing for women trying to conceive at advanced maternal age

For women trying to conceive over the age of 35, partnering with a functional medicine provider in addition to their OB/GYN or reproductive endocrinologist can help optimize the body’s internal environment through a highly personalized approach. Identifying and addressing factors including nutrient deficiencies, toxin exposure, insulin resistance and cardiometabolic health, sleep disturbances, and gut health not only has the potential to enhance fertility but also support a healthy pregnancy, healthy baby, and maternal health postpartum.  

Fertility is not a countdown clock, it’s a biological conversation. Age informs the approach and awareness, while biology impacts the outcome. Many women are able to conceive and have healthy pregnancies with the right support in place.

An note from WeNatal on starting the conversation of advanced maternal age

Advanced maternal age often brings more questions, but it can also be an invitation to approach fertility with greater intention and support. As Dr. Cindy shared, fertility after 35 is not defined by age alone. Egg quality and reproductive health are shaped by factors we can influence, including inflammation, metabolic health, nutrient status, stress, sleep, and the overall internal environment that supports hormone signaling and cellular function.

That’s why WeNatal is excited to partner with the UltraWellness Center to support their upcoming UltraLearning Series Functional Fertility Webinar on February 12, 2026. This webinar is a compassionate, empowering conversation for individuals and couples seeking clarity, confidence, and actionable tools rooted in functional medicine. Join Dr. Cindy Geyer and Lisa Dreher, MS, RDN, LDN (and WeNatal’s Nutrition Director) as they guide a thoughtful discussion designed to help you feel informed, supported, and not alone as you take the next steps in your fertility journey.

Nutrition plays a critical role in this process, especially in the 3–6 month preconception window when eggs and sperm are maturing. WeNatal for Her, Egg Quality+, and Omega DHA+ were created to support this foundational phase by offering targeted, evidence-informed nutrient support alongside the larger pillars of fertility care. Not as a cure-all, but as steady support while you build a strong foundation for conception and pregnancy.

Wherever you are on your path to parenthood, we’re honored to be part of the conversation and to support you every step of the way.

Click Here to register for the UltraLearning Series: Functional Fertility Webinar

RELATED: Protein for fertility & pregnancy: The complete guide for men and women 

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