Abstract Background To describe the institutional learning curve and neonatal outcomes of fetoscopic laser photocoagulation for Twin-to-Twin Transfusion Syndrome (TTTS) following the implementation of a fetal therapy program in a tertiary reference center in Brazil. Materials and methods This retrospective cohort study analyzed 31 monochorionic diamniotic twin pregnancies complicated by TTTS that underwent fetoscopic laser ablation between January 2019 and December 2024. Procedures were classified as complete Solomon, incomplete Solomon, or selective photocoagulation. Primary outcome was neonatal survival (double, single, or none). Secondary outcomes assessed associations with Quintero stage, coexisting complications (selective fetal growth restriction—sFGR or twin anemia–polycythemia sequence—TAPS), and Solomon completeness. Results The mean maternal age was 29 years, and the mean gestational ages at TTTS diagnosis and fetoscopy were 20.5 and 21.4 weeks, respectively. Most cases presented in Quintero Stage III (61.3%). sFGR occurred in 20 pregnancies and TAPS in five. Complete Solomon ablation was achieved in 84% of cases. Dual survival occurred in 6.4% of complete procedures and single survival in 38.7%. No significant difference in survival was found between complete and incomplete Solomon techniques ( p = 0.356). Survival outcomes differed significantly across Quintero stages, with all Stage I and II cases achieving survival of at least one fetus ( p = 0.002). Conclusion Fetoscopic laser ablation for TTTS is feasible and yields acceptable perinatal outcomes within a public tertiary hospital, even during the program’s early learning phase. Early diagnosis, efficient referral pathways, and continued team training are essential to optimize results and strengthen fetal therapy services in resource-limited settings.