To compare outcomes between interventional and expectant management of monochorionic twin pregnancies complicated with early severe intrauterine growth restriction (IUGR). We studied a series of selective IUGR defined as an AC<5th centile and absent or reverse end-diastolic flow in the umbilical arteries before 18+6 weeks, between 2011 and 2017. Treatment options included selective fetoscopic laser coagulation (SFLC) of inter-twin anatomoses, cord coagulation (CC), or expectant management (EM). Discordance in EFW and gestational age at diagnosis were considered as potential predictors for perinatal survival. A total of 74 cases were identified: 23 diagnosed <16+0 weeks (group 1) and 51 ≥16+0 weeks (group 2). In group 1, 3 were managed by SFLC, 9 by CC and 11 had an EM. The overall survival was 33,3% (2/6), 33,3% (6/18) and 86,3% (19/22) respectively. Intrauterine demise of the co-twin occurred in 33,3% (1/3), 33,3% (3/9) and 9,1% (1/11) respectively and was associated with 100% mortality in the smaller twin following SFLC and 18,2% (2/11) with EM. When discordance in EFW was <30% survival of both twin occurred in 100% with EM. In group 2, 10 were treated by SFLC, 27 by CC and 14 underwent EM with overall survival of 25% (5/20), 42,6% (23/54) and 67,8% (19/28) respectively. Intrauterine demise of the co-twin occurred in 60% (6/10), 14,8% (4/27) and 28,6% (4/14) respectively and was associated with the death of the smaller twin in 90% (9/10) following SFLC and in 35,7% (5/14) with EM. When discordance in EFW was <30% both twins survived in 70% of cases managed expectantly. Unexpected spontaneous demise occurred with EM in 13,6% (3/22) and in 21,4% (6/28) in cases diagnosed <16+0 weeks and ≥16+0 weeks respectively. Early IUGR is at high risk of fetal demise. Expectant management is a valid option as some will improve and allow a favourable neonatal outcome with a low rate of unexpected spontaneous fetal demise during follow-up.