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| Complete the Boss Rush as LilithImmaculate Conception|
Immaculate Conception is an unlockable passive item added in Afterbirth.
- Upon picking up enough heart pickups, Isaac gains a permanent angelic familiar and generates a soul heart drop. Possible familiars include:
- Holy WaterWhen Isaac receives damage, the bottle breaks and a puddle of blue creep forms, which damages non-flying enemies, similar to Lemon Mishap. The bottle is reformed upon entering a different room.
- Guardian AngelSpawns an orbital familiar that blocks enemy projectiles, deals contact damage to enemies, and increases the speed of all orbital familiars.
- Sworn ProtectorAn orbital angel which does 7 contact damage per tick and blocks enemy shots. Upon blocking 10 shots in a room it drops an eternal heart.
- The RelicIsaac is followed by a small blue cross that will drop a Soul Heart every 4 rooms.
- SeraphimAn angel familiar which follows Isaac and fires homing tears which deal 10 damage at -25% shot speed and a reduced fire rate.
- The first and second familiars will spawn after picking up 15 heart pickups each. The third, fourth, and fifth familiars will spawn after picking up 30 heart pickups each. No further familiars will spawn.
- Red, soul, and black hearts all count towards spawning a familiar.
- Items that directly add health such as Yum HeartRestores 1 whole red heart., Book of RevelationsAdds 1 soul heart, increases the chance for a Devil or Angel Room to appear, and increases the chance for the next boss to be a Horseman (except on XL floors and floors with fixed bosses such as Mom)., Satanic BibleUpon activation, Isaac gains a black heart., and The NailAdds one soul heart and allows the breaking of rocks and damaging enemies by simply walking over them. Increases damage and decreases speed. All effects except for the Soul Heart wear off upon leaving the room. do not count towards spawning a familiar.
- Only one of each type of familiar can be spawned.
- This item is the angelic counterpart to Cambion ConceptionAfter taking damage a certain amount of times, a permanent demonic familiar spawns..
- The Lost can pick up soul and black hearts despite having no health and thus can activate Immaculate Conception.
- Keeper cannot even encounter hearts and thus the item is useless for him.
- Immaculate Conception refers to the Catholic teaching that the conception of the Virgin Mary was free from original sin.