The Binding of Isaac: Rebirth: The Binding of Isaac: Afterbirth+

25% of the reviews written in January and February 2017 call the content lazy, rushed or reskinned, or hold it up against Antibirth, the free fan expansion released shortly before, and 16% of that window's reviews name Antibirth outright. Reviewers point to enemies built from existing sprites, new bosses that are larger or merged versions of old ones (Big Horn from Little Horn, Rag Mega from Rag Man and the Haunt, Sisters Vis from the Cage), and recolored items. "It's sad when a free mod adds more interesting content then a paid dlc." Defenders answer that Afterbirth+ was announced as a small expansion built around mod tools and that Antibirth had years of development behind it. The comparison fades after 2017, and later reviewers mention that Antibirth's developers went on to work on the game's later content.

Reviewers report startup failures in every period. At launch, many buyers could not start the game with Afterbirth+ installed ("I can't even launch Isaac if I have this DLC installed."), and the fixes passed around included reinstalling Visual C++ 2015 and working around antivirus programs that flagged a bundled editor. The store page listed only Rebirth as a requirement, so buyers without Afterbirth found the game refused to load. Early patches also hid or wiped some save files ("Purchasing A+ cost me my save file."), and a few reviewers lost runs to crashes in the Delirium fight. Reports kept coming after the launch patches, among them "Binding of Isaac Afterbirth+ cannot even launch.", written years later.

The share of crash reports grows after Repentance: 17% of the reviews written since its release describe a black screen, a game that closes itself, or a launch that only works with Afterbirth+ disabled, peaking at 28% of the reviews written in 2022. Reviewers disagree about the cause. Some say "For TboI to work with DLCs, you have to own every single one, including Repetance+ Beta." Others blame a broken mods folder ("it works fine without mods"), though more of them say deleting their mods changed nothing. Mac players say it stopped running ("Afterbirth Plus is no longer compatible for Mac users"), one of them after an operating system update, and Steam Deck players write that "afterbirth+ is broken on steamdeck since november and theres been no fix". 34% of these crash reports still recommend the expansion, and several of them say they like the game and ask for a fix.

22% of the reviews written in January and February 2017 bring up the ways Afterbirth+ made the game harder, mostly to complain. They name portals that spawn enemies from the first floor onward, invulnerable stone fatties that push the player around and block shots, chests that turn into spike chests ("No one slowly walks up to a chest to open it."), treasure rooms with no item, rooms packed with Blastocysts, tanky bosses with untelegraphed attacks, and an unlock that adds half soul hearts after repeated restarts, which one reviewer summed up as paying "to have your game actively penalize all of your future runs, forever." Their objection is that luck now counts for more than skill: "Portals increase the random factor and not the skill." A minority welcomed a harder game, told critics to "git gud", or wrote that "the portals aren't that hard and itemless item rooms almost never happen stop complaining". The early patches toned most of these down, and this complaint largely disappears after 2017.

The new final floor and boss draw complaints in every period. At launch, reviewers objected that the Void stitches together rooms from earlier floors ("Final floor is a bunch of rooms from other levels stitched together with literally zero new assets added.") and that reaching it depended on beating Hush quickly or on a random portal. Reviewers describe Delirium, a boss that shifts between earlier bosses, teleporting onto the player, and complain about its huge health pool with damage scaling, its immunity to the Chaos Card and, at launch, its single frame of animation. "Delirium is the worst boss in the game, and despite the balance changes, he can and will telefrag you." Reviews written after Repentance still name it ("even in repentance delirium is still a horribly designed un-fun boss fight, even if the concept is cool"). A minority like the fight and its place in the story: "I genuinely enjoy The Void and Delirium, you guys are just mean".

Greedier, the hard version of Afterbirth's Greed mode, is described as Greed with fewer coins, faster waves, more champions and a second phase for Ultra Greed full of explosions: "greedier mode is just greed mode but less fun". Reviewers say a run is decided by whether an early item drops, and that the mode is required for unlocks, so completionists must grind it with every character. Some launch reviewers who found Greed too easy welcomed it ("This is the ACTUAL Greed Mode I was looking for in Afterbirth."), and one credits its lower jam chance with making the Holy Mantle and Keeper unlocks reachable. Later reviews still single it out, and a 2026 review asks for it to be rebuilt with the newer room types.

Some reviewers complain about how the expansion is sold. Shortly after launch it became available only in bundles, so owners cannot gift it to friends who already own part of the set ("LET ME GIFT IT TO MY FRIEND WITHOUT BUYING THE BUNDLE"), and later buyers ask "Why in the kentucky fried fluck can you not buy this directly?" Others object to a DLC that requires another DLC and to paying for Workshop access ("Real nice i have to spend $10 just to use mods. Thanks"). A few launch reviewers said the store page's multiplayer listing implied online co-op when only local co-op was available. One later review asks to "PLEASE MAKE THE DLC PURCHASE PROCESS MORE STREAMLINED".