Introduction: Infertility therapies have markedly increased the incidence of multiple pregnancies and concomitantly monozygotic twinning. In utero death of one monozygotic twin predisposes the survivor to death and serious morbidity from hemodynamic collapse, thromboplastins, or microemboli. The optimal management of such cases, however, is unclear. Methods: We compared single-twin demise to similar clinical conundrums in the past to try to derive a model for the data needed to reach a consensus. Results: The management of such pregnancies is very controversial as the clinician must balance the risks of damage to the survivor by temporizing against the risks of prematurity and the possible futility of damage already having occurred because it is impossible to precisely time and document when the damage occurs. While there is not yet a standard consensus, the trend is towards more aggressive management either by rapid delivery or transfusion to ameliorate possible damage, but the risks are still very high for the survivor. Conclusions: The trend is moving towards more aggressive management than previously. We pose several questions that still remain to be answered to derive a consensus as to management, but it is unlikely that the required data could ever be obtained in a rigorous, randomized fashion.