AbstractFeto‐fetal transfusion syndrome contributes heavily to high rates of perinatal mortality and morbidity in monochorionic multiple pregnancies. Its prenatal management has been controversial for at least 25 years. We review the recent literature in order to present the basis for a pragmatic reappraisal of the management of this condition. Laser surgery of the chorionic plate inter‐twin anastomoses is the best first‐line treatment when the syndrome develops before 26 weeks' gestation. Survival (including quality of survival) and gestational age at delivery are improved when compared to serial amnioreduction. Second‐line treatment options include repeat‐laser, intra‐uterine blood transfusion, serial amnioreduction, selective feticide using bipolar cord coagulation or elective delivery, depending upon gestational age and the severity of the disease and its complications. We have found that fetoscopic placental surgery has proven itself over simplicity of amnioreduction. There is no evidence that treatment should be customized according to the stage of the disease at diagnosis. Early recognition of the syndrome through fortnightly serial ultrasound follow‐up of all monochorionic pregnancies should ensure timely referral and make up for geographical constraints. Laser surgery should now be available in fetal medicine units that are managing at least 20 cases per year. Copyright © 2005 John Wiley & Sons, Ltd.