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Background: Fetal myelomeningocele (fMMC) repair yields superior outcomes to postnatal repair and is increasingly offered at select fetal centers. Objectives: To report the fMMC referral process from initial referral to evaluation and surgical intervention in a large fetal referral center. Methods: We conducted a retrospective cohort study of patients referred to Texas Children’s Fetal Center for fMMC between September 2013 and January 2018, reviewing the process from referral to final disposition. The stepwise evaluation included a phone interview followed by multidisciplinary consultation at our fetal center. We modified the Management of Myelomeningocele Study inclusion and exclusion criteria to allow a maternal body mass index of 35–40 on an individual basis. Results: A total of 204 referrals were contacted for a phone interview; 175 (86%) pursued outpatient evaluation, and 80 (46%) of them qualified for repair. Among the eligible patients, 37 (46%) underwent fetoscopic repair, 20 (25%) underwent open repair, and 17 (21%) declined prenatal surgery. Of the 89 noneligible patients (53%) excluded upon outpatient evaluation, 64 (72%) were excluded for fetal and 17 (19%) for maternal reasons. No hindbrain herniation (16%) and maternal BMI and/or hypertension (5%) were the most common reasons for fetal and maternal exclusion, respectively. A total of 31% of our referral population underwent fetal surgery. Conclusions: A small percentage of fMMC referrals ultimately undergo prenatal surgery. Stepwise evaluation and multidisciplinary teams are key to the success of large referral programs.